​How do you go about choosing your suture thread? Absorbable sutures may include polyglycolic acid, chromic catgut, or glycerol-impregnated catgut. Non-absorbable sutures are typically made of silk, Prolene, or nylon. Suture materials may be synthetic or natural, and they can be mono- or multifilament. Sutures may also be braided, unbraided, or coated. Sizes of suture materials also vary greatly. A 3.0-sized thread is a lot bigger than a 6.0-sized thread, for example.​

Keep these key principles in mind: The time it takes for the thread to be absorbed is dependent on the tissue type and thickness, the size and type of the thread, the condition of the patient, and the absorption half-life of the product. Many online guides can help you learn more. Some sutures will be absorbed in five to seven days; some may take more than 200 days to disappear completely.

Vicryl Rapide vs. Vicryl

Vicryl Rapide and Vicryl are absorbable sutures and are potential choices for repairing nail bed lacerations. Vicryl Rapide is a new and improved form of Vicryl, and may be more commonly used. Vicryl Rapide absorbs more quickly than other absorbable sutures, including Vicryl. Vicryl Rapide typically is completely absorbed after 42 days.

The most important thing to know is that after five days, Vicryl Rapide becomes 50 percent weaker than it was when you first put it in. No traction is left at all by day 14. Take this into consideration when you are assessing the wound. This is enough time for a pediatric finger laceration to heal if it is appropriately splinted and followed up.​

Polyglycolic acid derivatives such as Vicryl Rapide and Vicryl are far superior to non-absorbable sutures for wound healing, but problems still occur with their use, often because they are placed inappropriately or in areas with high tension.

A randomized prospective study in the Journal of Hand Surgery investigated Vicryl and Vicryl Rapide in 60 pediatric hand surgery cases. Thirty of the patients received Vicryl and the other 30 received Vicryl Rapide. The results showed that five "problems" occurred in the Vicryl treatment group and none in the Vicryl Rapide group (P=0.03).

All of the problems were related to the delayed absorption of the Vicryl suture material. The author concluded that Vicryl Rapide sutures are "more suitable than Vicryl ones in pediatric hand surgery." (2005;30[1]:90). Vicryl Rapide also has an antibiotic coating called triclosan. Studies are limited, but the coating has shown lower the rates of infection.

The major difference between Vicryl and Vicryl Rapide is in the composition and handling. Typical Vicryl is made up of a polyglycolic acid called polyglactin 370. Providers reported this coating made tying their knots more difficult, but it did decrease tension through the tissue and did less damage to the wound. The advantage of Vicryl Rapide is that it is a type of polyglcolic acid called polyglactin 910, which is not only easy to use but also easier to tie and secure. Its tension is better, and the absorption rates are relatively the same.

We will discuss suture materials in depth in future blogs, and talk about the differences between nylon and Prolene and when to use deep sutures for various parts of the body. The pediatric population requires strict guidelines and tension relief because of the difference in their skin composition, healing times, and body mechanics.

Tetanus Status: Pay Attention to These Kids!

When does a child first receive a tetanus shot? The American Academy of Pediatrics suggests the DTaP (diphtheria, tetanus, and pertussis) at ages 2, 4, and 6 months and again at 15 to 18 months. A DTaP booster is recommended for children ages 4 through 6 years old. Don't forget to administer appropriate boosters if your patient requires one. If parents are wary of receiving vaccines in the ED, they have 24 to 72 hours to discuss it with their pediatrician and have it still be effective.

Recommended guidelines from the CDC on Td vaccine.

Next month: Antibiotics for open finger fractures (such as tuft fractures), using Dermabond vs. suturing for nail bed lacerations, and referrals and additional treatments for hand injury patients.

​Our pediatric patient population is special, small humans with distinctive needs, medication doses, and unexpected challenges. The more you use the simple approach to pediatric emergency department procedures, the more you will experience faster, smoother, and better results.​

You don't have to get fancy unless of course you have a Child Life Program in your department. The materials are simple and the skill is straightforward. Adding a sense of humor, learning the words to "Frozen," and laughing with your pediatric patient (whenever possible) will also help ease the tension.

Children, just like adults, don't like when you lie to them. It's important you give them just enough details to be able to complete your procedure. Be careful not to divulge too much scary information because it will just make treatment more difficult. Be aware of age-appropriate milestones and emotional development. Use suitable language to describe things to your patient, and involve the parent the entire time. Consider having mom or dad hold the gauze or a Band-Aid. Any complex or scary conversations should be held outside the room away from children's ears. Remember, don't use medications if they are not indicated and you can get through a procedure without them. Some kids are actually braver than you think. But do not hesitate to use light sedation if it will be safer for the patient, less stressful for the parent, and easier for you.

Each age group should reach specific personality and emotional milestones, according to the American Academy of Pediatrics. All children are different, and this guideline may assist with decision-making.​

The Pause

How old is your patient? What milestones has this child reached? Does the child seem responsive to treatment? Are there any emotional development delays? Discuss the procedure with the parent and determine the best plan. Discuss pros and cons of light sedation. Ask the parents how the child may handle shots and gore. Some children, even 4-year-olds, are actually quite brave and are willing to do the procedure without hassle. It may be helpful to review Erikson's States of Psychosocial Development before proceeding: http://bit.ly/PsychosocialChart. Use your best judgment and then proceed with a set plan. Apply LMX 4% cream or EMLA cream to the base of the finger to make the digital block injection of anesthesia less painful.

The Approach

Identification of injury and the extent of the injury (Fracture? Multiple lacerations? Nail condition?).

Perform radiograph if indicated.

Determine plan (Sedation? Forms of anesthesia such as lidocaine?).

Inject a digital nerve block into the affected finger.

Clean and explore the wound.

Suture and repair the nail bed laceration(s).

Apply Dermabond or other adhesive glue to nail to secure it in place.

Repair any other lacerations.

Add dressing and splinting as indicated.

Determine if tetanus update is needed and discuss immunizations.

Give antibiotics if indicated.

Develop a follow-up plan

The Procedure

Assess the child's milestones and emotional development. Assess the wound and then discuss the plan with the parents. Include the child in the conversation only if appropriate.

Some parents prefer the use of a papoose or child procedure board that limits movement while you work. It is the right of the parent to refuse pain or anxiolytic medications for her child. You may want to at least offer ibuprofen or acetaminophen if the parents refuse sedation.

Apply topical LMX 4 % cream or EMLA cream to base of the finger. Cover it with Tegaderm or gauze to help with absorption.​

Agent

Duration

Max Dose

Lidocaine

Medium (30-60 min)

Without epinephrine: 4.5 mg/kg, not to exceed 300 mg

Lidocaine + Epinephrine

Long (120-360 min)

With epinephrine: 7 mg/kg, not to exceed 500 mg

Bupivicane

Long (120-240 min)

Without epinephrine: 2.5 mg/kg, not to exceed 175 mg total dose

Bupivicane + Epinephrine

Long (180-420 min)

With epinephrine: Not to exceed 225 mg total dose

Review your department's protocol and safety measures if you have chosen light sedation (i.e., anxiolytic +/- anesthesia, pain control) for your patient. I use intranasal Versed per our hospital protocol. All safety measures must be in place; it is your responsibility to review these guidelines.

All intranasal Versed doses are weight-based in kilograms. Determine the appropriate dose and administration per your protocol and current drug guidelines.

Set up the digital block once the child is calm, appropriately medicated, and ready for the procedure.

Allow at least 15-20 minutes for the anesthesia to take full effect after application.

Clean the wound with soap and water.

Complete the digital block using 1% buffered lidocaine. Massage the anesthesia into the base of the finger along the nerves.

You may decide to use a finger tourniquet to control the bleeding. A clean, dry field will allow you to place sutures more effectively. If a finger tourniquet is unavailable, you can use a rubber band over a piece of gauze around the base of the affected finger.

Replace the nail in the original position as best as possible. Use Dermabond or other skin adhesive to secure the nail in place directly over your applied nail bed sutures. The use of nondissolvable sutures through the nail and into the skin is a practice that is no longer needed. (See video.)

The nail not only is the best and most effective barrier over the injury but also allows the new nail to grow out straight. It is important to maintain the opening of the cuticle for at least one week to avoid scarring and a deformed nail. You can pack open the cuticle with a piece of gauze if the nail is not available. Other providers have used cut-out pieces of the suture packaging. The packaging is cut in the shape of the missing nail and inserted into the cuticle. This topic has not been researched thoroughly but may be of use in your practice. Providers may also use a folded piece of Steri-Strip as a fake nail to keep the cuticle open. Just make sure it is folded flat, and no sticky portions are open.

Speaking of Steri-Strips, use these to secure the nail if you think the adhesive needs added protection.

Dress the wound with a nonadherent dressing. Show parents how to care for the wound. It should be redressed twice a day.

Follow up with hand specialist in three to seven days.

Discuss tetanus, immunizations, and antibiotics with parents if there is an open fracture.

Next month, we will discuss antibiotics for open finger fractures (such as tuft fractures) and the use of Dermabond vs. suturing for nail bed lacerations. Then we will touch upon referrals and additional treatments for hand injury patients.

We promised you short, sweet, and simple solutions, and we plan to deliver. Many of the tools we want you to use may have merely been forgotten. The steps to complete these simple solutions will require just a few minutes of brushing up on the basics while watching our how-to videos and reading our step-by-step blog posts.

One of the lengthiest procedures in the emergency department can be eye irrigation. Some patients may need 5-15 liters of normal saline flush, which can take hours. Alkaline products need ample flushing and constant reevaluation with pH checks to avoid ocular burns. Patients can get frustrated and often times will ask you to stop the procedure. Keeping up with an eye irrigation patient can be difficult for providers as well, and create a long stay.

This patient suffered from alkaline burns to both eyes. He is being treated with normal saline irrigation using a nasal cannula. Photo by Martha Roberts.

Many providers have traditionally used the Morgan Lens in the ED to assist in ocular irrigation. The process is time-consuming and sometimes painful, and it can cause corneal abrasions. Patients, especially children, have difficulty tolerating the lens. Insertion can be agonizing if proper anesthesia is not obtained. Depending on the patient, the lens may need to be replaced several times if there are multiple liters of irrigation. Many urgent care facilities and some EDs may not stock the Morgan Lens and need an alternative approach to treatment. Finally, the Morgan Lens can be harmful to the patient if the normal saline infusion bags run dry. Many times providers will be unable to monitor the lens/bolus. This can be frightening for the patient and can cause ocular trauma.

One of the best ways to irrigate the eye involves using IV saline via a nasal cannula and connector piece from a Salem Sump kit. This procedure is far less invasive than using the Morgan Lens and is less traumatic for the patient. Patients feel less claustrophobic and are able to move freely. It is an effective and forgotten form of treatment to consider the next time you need to irrigate a patient's eye.

The Approach

Careful but speedy examination of eye

Initial ocular anesthesia (i.e., tetracaine)

Oral pain or anxiety control

Set up an irrigation system using nasal cannula and normal saline

Repeat boluses of normal saline and pH status checks

Consult with poison control and ophthalmology as needed

The Procedure

Begin manual flushes of the eye as soon as possible after carefully (but quickly) examining the patient's eye. Do this while the irrigation system is being set up. The sooner the caustic agent is washed from the eye, the better.

Check the pH of the eye for a baseline. Your goal is to get as close to 7.0 as possible.

Sample of pH strip used for ocular pH testing.

Discuss with ophthalmology and poison control. If the patient has brought in the bottle of the chemical he was exposed to, report each ingredient to the specialists.

Each Salem Sump kit contains a small, white plastic connector piece. This piece is key to attaching the NS IV line to the nasal cannula.

Salem Sump connector piece.

You may use tape to reinforce the connection, but the connection alone is quite secure once placed.

Set up a piggyback line to the IV connection so more than one bolus can run at a time and you can alternate without stopping.

Consider giving the patient oral pain control (if the caustic agent is painful) or antianxiety medication such as Valium to relax him during this lengthy procedure.

Administered ocular anesthesia into both eyes. This pain relief will help the patient tolerate the initial NS bolus. Additional numbing drops can be administered between boluses.

Have the patient remove all top layers of clothing. This procedure will get them wet. Then position the patient at a 30-degree angle on the stretcher.

Lay the nasal cannula over the bridge of his nose so that the prongs are directed to the inner canthus. If both eyes are affected, separating the two prongs will allow saline delivery into both.

If only one eye is affected, both prongs can be directed to a single eye.

Allow the NS to flow from the bag into the IV line and over the patient's face, across his eyes. This flow is quite powerful and will copiously irrigate the eyes. The patient does not need to keep his eyes open.

Continue this as needed and until the pH is at an acceptable level.

Follow up with ophthalmology as recommended.

Watch a video demonstrating this technique. The ports typically used for oxygen deliver the normal saline to both eyes, left. If one eye is affected, you can shift both prongs to that eye. Give ocular anesthesia before the first bolus. A patient may keep his eyes closed because the saline will bathe the inner canthus and inner eye. The saline is delivered at a fast rate, allowing for generous irrigation. The Salem Sump connector piece, right, connected to the NS bolus bag. Photos by Martha Roberts.

Cautions and Pearls

Patients get wet when you do this procedure. This also means they get cold. Consider frequent hospital gown changes, appropriate drainage techniques (such as using drainage headboards, towels, Chux, etc.). You should also give your patient some blankets. Use warmed NS if available.

Report all ingredients to poison control for assistance.

Remember to check the pH. It's important to wait 10 minutes between each NS bolus to check the pH level because it can continue to rise.

This is a long procedure at times and can cause anxiety. Absolutely use a numbing agent if the patient can tolerate it and frequently check on the patient. Reassurance can play a major role, but when it can't, anxiolytics can be of assistance.

Complete a full eye exam if possible, but do not delay irrigation tactics.

Discuss home medications with ophthalmology such as erythromycin or other antibiotics before discharge.

Tell patients to avoid wearing contact lenses for at least two weeks.

Toxicology Tip of the WeekAlkaline cleaning products can cause burns to the skin or face. Straightforward chemical burns from these products, however, generally only affect the eye. The solution is not absorbed systemically nor does it enter the nasal pharynx.

​Alkaline is EverywherePatients often present with known complaints of chemical burns to the eye, but some patients may not know they have an alkaline burn. A single case report of a chemical keratitis involved alkaline gas from a deployed passenger airbag. The authors noted that inflation of an airbag converts sodium azide to nitrogen gas. The bags are vented so that nitrogen and residual byproducts of combustion, such as alkaline gas, which could cause injury. (Ann Emerg Med 1992;21[11]:1400.)

Sometimes the best solution is the simple one, and this series of handy tricks will help you master the most difficult problems. The majority of the procedures require old-school techniques with a new flare. Many of these might have been forgotten, but just a few minutes of brushing up on the basics while watching our how-to videos and reading our step-by-step blog will get you ready.

How many times have you removed objects from someone's ear? If it's too many to count and you have been successful, then you don't have to reinvent the wheel. But if you are looking for a different way to remove objects such as earbuds, insects, tips of glasses, wads of cotton, or other bizarre findings, then topical cocaine can help you painlessly remove foreign objects from the ear.

It is almost impossible for any patient to hold still while a clinician removes a deeply imbedded foreign body from the ear canal. It's just too sensitive of an area. Some foreign bodies can be removed with irrigation, and those easily seen and grasped can be removed with a gentle hand. IM/IV conscious sedation may be tried, but it is often not totally effective. A number of ways to anesthetize the canal have been suggested, but they are not readily effective. Topical cocaine is about the only way to anesthetize the canal enough, without distortion of anatomy, to gain successful topical anesthesia.

Importantly, don't persist if the foreign body cannot be removed. Persnickety foreign bodies are best removed by a specialist, and there is no shame in referring such cases. Creating a bloody mess in the canal makes it more difficult for patient and specialist.

The Approach

Identify the foreign body in the ear of the adult patient.

Use 4% or 10% cocaine hydrochloride solution.

Administration of solution into affected ear, then wait!

Painless removal of the foreign body

Procedural Tool Selection

The following tools may be of use to you. It's time to get acquainted with them if you are not familiar with the way they work.

The PauseWho is the wrong candidate for this procedure? You may have guessed it, but the pediatric population is excluded from this procedure. The use of cocaine in children is "limited by possible toxicity. (Emerg Med Clin North Am 1989;7[1]:117.) IM ketamine (4-5 mg/kg IM) is the best way to sedate a child to remove a stubborn foreign body of the ear canal.

The Procedure: Short and Sweet

Complete a full head, ears, eyes, nose, and throat (HEENT) exam.

Identify the foreign body at large. Use a microscopic technique. Good visualization is key. One studyfound that ear canal lacerations occurred in 48 percent of patients where removal was attempted without the use of a microscope, compared with only four percent where a microscope was used. (Laryngoscope 1993;103[4 Pt 1]:367.)

Position patient supine with the affected ear up. Fill the entire canal with cocaine. Allow cocaine to sit in place a full 20 minutes before attempting foreign body removal.

Remove the cocaine solution by aspiration or allow it to drain.

Use a nasal speculum to open the ear canal or direct vision to grasp the object, being careful to avoid the tympanic membrane. The alligator forceps are often the best instrument to grasp the object. Gently insert alligator or bayonet forceps to remove the foreign body. Be careful to avoid excessively touching the canal's surface; that's the most sensitive area.

Re-examine the canal to ensure that the object has been completely removed.

Follow-up is not routinely indicated unless hearing or other ear complaints persist.

Cautions

Note that local anesthesia can be invasive and typically is used for complicated foreign body removal. An uncomplicated foreign body should be removed without additional measures because the external ear canal is sensitive and has incredibly delicate anatomy.

Did you check both ears? We hope so, because where there is one….

Complete a full HEENT (head, ears, eyes, nose and throat) exam.

Procedural sedation is required for foreign body removal of any kind in children. IM ketamine is probably the best way to sedate a child.

Is it a bug? Live insects in the ear should be stopped dead. You must first immobilize them before removal. The use of mineral oil, microscope oil, and viscous lidocaine have all been used to put them down. (Laryngoscope 2001;111[1]:15.)

Can't quite get it? Complications may occur, and we suggest contacting ENT (especially during business hours for immediate referral) if all else fails. If you continue to poke around in the ear, it may result in infection, perforation, pain, or other unintentional injury. (Laryngoscope 2003;113[11]:1912.)

Contraindications

You must consult ENT to have the foreign body removed by microscope and speculum if you are concerned about a tympanic membrane perforation.

Approach with caution if a button battery, hearing aid battery, or other electrical device is present. These, too, should be referred to ENT for removal. These electronic bodies are time-sensitive and potential liquefaction necrosis may lead to subsequent tympanic membrane perforation and further complications. In fact, irrigation should never be attempted in such cases because it accelerates the necrotic process. (Ear Foreign Body Removal Procedures. Medscape. Feb. 16, 2016; http://bit.ly/2aCnUQS.)

Tip of the Month

This month's tip comes directly from our patient, Dr. James Roberts. Although he is not our patient or model very often, celebrities are just like us! When cruising back through the Virginia area, Jim got a piece of this microphone ear bud stuck in his ear. Although Martha Roberts, NP, offered to remove it, he decided to head to the local ED where the helpful Dr. J. J. Sverha was ready to try a seasoned trick of the trade.

Jim was suffering from severe pain from his earbud accident after trying to pick and prod at it himself. After hours of unsuccessful attempts, he turned away his deaf ear, and let Dr. Sverha remove it carefully with this very procedure. Jim suggests using the least invasive techniques to remove objects from the ear. When positioning the patient, always have him lie on the unaffected side and drip the cocaine slowly into the ear. Special thanks to Dr. Sverha for his careful handling and success with Jim! The use of cocaine solution provided remarkable anesthesia.

​Insider Tips Worth Trading

Acetone has been used successfully to remove chewing gum, Styrofoam, and superglue from the ear canal. (J Laryngol Otol 1995;109[12]:1219.)

Ethyl chloride has been used to remove Styrofoam beads from the ear canal. (J Accid Emerg Med 2000;17[2]:91.)

We are going to get up close and personal this month to talk about hemorrhoids. You should be familiar with these painful offenders because half to two-thirds of people between 45 and 65 will suffer from their cruelty. (Am Surg 2009;75[8]:635.) Patients may seek emergency department care if they experience bleeding or severe pain from hemorrhoids.

Hemorrhoids are highly vascular structures that are round or oval in shape. They arise from the rectal and anal canal, and sometimes appear around the anus itself. It is important to note that hemorrhoids do not have arteries and veins but special blood vessels called sinusoids, connective tissue, and smooth muscle. (Beck, DE, et al. The ASCRS Textbook of Colon and Rectal Surgery, Second Edition. New York, NY: Springer New York, 2015, p. 175.) Hemorrhoids at times can exist within the anal canal and be completely painless because sensory innervation to the rectum is primarily visceral. (Roberts JR, Hedges JR, et al. Clinical Procedures in Emergency Medicine. Elsevier, Philadelphia, PA, 2015, p. 880.)

Hemorrhoids protrude around the anus and swell, causing significant pain, when they become inflamed or irritated. The straining from constipation and poor diet choices may be the main cause of hemorrhoids, although lack of exercise, aging, pregnancy, and hereditary may also contribute to their formation. Very rarely are hemorrhoids cancerous. Fissures or tears in the skin around the rectum may occasionally accompany hemorrhoids.

Not all external hemorrhoids contain clots; some are just swollen and irritated and not amenable to incision. Some hemorrhoids are swollen, soft, and compressible, and may be tender. If the hemorrhoid is not tense or a clot is not palpated, topical corticosteroids and sitz baths are the best intervention.

Thrombosed external hemorrhoids are readily drained in the ED. Surgical intervention for internal hemorrhoids is not an outpatient procedure and usually is a last resort. Hemorrhoid surgery can be a difficult procedure for many to endure, and patients who suffer from long-term hemorrhoid complaints may benefit from a visit to a colorectal surgeon. A colonoscopy or sigmoidoscopy may assist in ruling out more complicated or serious diagnoses.

​Anatomy ReviewHemorrhoids are veins in the rectum. They are normal vascular structures in the anal canal, arising from a channel of arteriovenous connective tissues that drain into the superior and inferior hemorrhoidal veins. They are located in the submucosal layer in the lower rectum and may be external, internal, or mixed based on their location relative to the dentate line. External hemorrhoids are located distal to the dentate line; internal ones are located proximal. Hemorrhoidal bleeding is characterized by the painless passage of bright red blood from the rectum with a bowel movement. Painful defecation is not associated with hemorrhoids unless they are thrombosed. Acute onset of perianal pain with perianal swelling suggests the presence of a thrombosed hemorrhoid.

​PresentationHemorrhoids can produce bleeding with a bowel movement, itching, pain, feces leakage, difficulty cleaning after a bowel movement, or tissue bulging around the anus. Patients may be able to see or feel hemorrhoids, or they may be hidden from view inside the rectum. Hemorrhoids are classified as internal or external; internal ones are best treated by medication and a surgeon, but acutely thrombosed external hemorrhoids are fair game for drainage in the ED or clinic. Neither type of hemorrhoid is painful unless complications develop.

Both internal and external hemorrhoids can develop clots in the vessels. A thrombosed hemorrhoid is extremely tender to palpation, and a thrombus may be palpable within the tense hemorrhoid. Internal hemorrhoids can also contain a clot, but more likely prolapse outside the rectum, causing significant pain and increased bleeding. Prolapsed internal hemorrhoids appear as dark pink, glistening, and tender masses at the anal margin. Thrombosed internal hemorrhoids can cause pain but to a lesser degree than external hemorrhoids. An exception is when internal hemorrhoids become prolapsed and strangulated, and develop gangrenous changes from the associated lack of blood supply.

External hemorrhoids are not typically graded, but internal hemorrhoids are according to the degree to which they prolapse from the anal canal. Grade I hemorrhoids are visualized on anoscopy and may bulge into the lumen but do not prolapse below the dentate line. Grade II hemorrhoids prolapse out of the anal canal with defecation or with straining but reduce spontaneously. Grade III hemorrhoids prolapse out of the anal canal with defecation or straining, and require manual reduction. Grade IV hemorrhoids are irreducible and may strangulate, and urgent surgery is required for grade IV internal hemorrhoids, though rubber band ligation is the most widely used procedure for other grades. Rubber bands or rings are placed around the base of an internal hemorrhoid. As the blood supply is restricted, the hemorrhoid shrinks and degenerates over several days. Banding is successful in approximately 70 to 80 percent of patients. (Roberts & Hedges, 2015.)

This current discussion concerns diagnosis and treatment of thrombosed external hemorrhoids only. These are covered by modified squamous epithelium (anoderm), which contains numerous somatic pain receptors, making external hemorrhoids extremely painful with thrombosis. Thrombosed external hemorrhoids are acutely tender and have a purplish hue, and occasionally a partially extruded clot can be seen. Patients present with acute onset of perianal pain and a palpable perianal "lump" from thrombosis. Thromboses of external hemorrhoids may be associated with excruciating pain as the overlying perianal skin is highly innervated and becomes distended and inflamed. Importantly, not all swollen external hemorrhoids contain an organized extractable clot, and incision of a swollen hemorrhoid is of no value unless a clot is present. A clotted hemorrhoid is generally very firm and discolored from the underlying clot.

Typical appearance of external hemorrhoids. Note the partially extruded clot from one thrombosed hemorrhoid. The other hemorrhoids are swollen, but are soft and do not contain a clot. Incision of non-thrombosed hemorrhoids should be avoided. They are treated with frequent sitz baths and topical corticosteroid ointments. (Photo by Martha Roberts.)

The ED is a place people will visit for this ailment, and you need to be ready. Hemorrhoids aren't just for grandmas and grownups but also occur in children and athletes. In fact, George Brett, one of baseball's Hall-of-Fame inductees, had to stop playing in the 1980 World Series because of hemorrhoid pain. Glenn Beck, a well known talk show host, took his treatment of hemorrhoids to the next level in 2008 by having surgery and speaking out about his case. He stated that the pain medications (opioids) only made his hemorrhoids worse and affected his mental state. (http://cnn.it/29iIAvV.) Stories like this give rise to concerns of pain control complications and addiction. ED interventions can help patients be well and learn about nonopioid treatments.

Now that you know a little bit more about hemorrhoids and their mercilessness, we are going to highlight some ways you can treat painful, thrombosed external hemorrhoids. Remember, internal hemorrhoids are not treated by minor surgery in the ED. We are also going to remind you that your craft requires compassion and that treatment should be carefully completed.

Multiple external hemorrhoids. Not all visible hemorrhoids contain a thrombosis. A clot produces a firm palpable mass. If a clot is not palpated, do not incise. Note partially extruded clot in one hemorrhoid. (Photo by Martha Roberts.)​

The PauseHow do we identify thrombosed external hemorrhoids and when do we need to intervene? A thrombosed hemorrhoid will be protruding from the anal canal around the anus. The hemorrhoid itself will appear dark blue or purple, and appear quite swollen. The hemorrhoid appears this color because of the collection of blood clots inside the hemorrhoid itself. This can cause significant pain, and incision and drainage may help with relief. Thrombosed external hemorrhoids that are not drained most likely will spontaneously rupture in one to three weeks and leave a skin tag behind. Sitz baths two to three times a day are often curative if a patient declines drainage in the ED.

The Approach

Provide an area of privacy for comfort. Professionalism, kindness, and caring are key to successful treatment.

Positioning this patient is variable. There are several ways to position the patient including prone, left lateral decubitus, or Sims knee-shoulder position. Our position of choice will be prone. Patients with breathing complications, obesity, claustrophobia, or anxiety may not be good candidates for this procedure.

A digital rectal exam should be completed with guaiac testing if indicated. Anoscope may not be needed for severely thrombosed hemorrhoids and too painful to complete.

A CBC and 500 mL bolus may be ordered if the patient reports copious bleeding.

Obtain IV access and administer sedation/pain control. IV opioids are best, providing some relaxation/sedation as well as analgesia. IV fentanyl, hydromorphone, and morphine are suitable options. Use appropriate dosing. Be sure to monitor the patient's airway during the procedure with end-tidal CO2 and oxygen saturation. Do not forget to document appropriately.

Clean the area well with soap and water and Betadine.

Apply LET, a combination of lidocaine (2%), epinephrine (0.1%), and tetracaine (0.5%), and wait 20 minutes. EMLA cream is also suitable, but can take up to one hour to work.

Ask the nurse, technician, or another provider to assist with initial investigating and setup.

Use 2-inch tape to tape the buttock apart. This will allow for free use of both hands and full exposure.

Locate the thrombosed hemorrhoid and prepare for analgesic injection.

Obtain a 25-gauge needle and 10 mL syringe for medication injection.

Obtain a suture kit and 11-blade scalpel for incision and drainage.

Use a single injection of buffered long-acting bupivicane (NOT LIDOCAINE) with epinephrine. Buffer the injection with sodium bicarbonate.

Infiltrate the thrombosed hemorrhoid just under the skin and over the dome of the hemorrhoid. Avoid deep injection, and inject slowly.

If full pain control is not achieved, you may advance the needle slightly and inject more analgesia.

Make an elliptical incision around the clot and direct it radially from the anal orifice. An elliptical incision should be made as opposed to a simple cut because premature closing of the incision may prevent clots from dissolving.

Squeeze the hemorrhoid with your fingertips to express clots.

Forceps may be used to remove residual clots.

Do not pack the hemorrhoids. Apply pressure to the site to control bleeding. Use a folded gauze to pad over the operative site and tape the buttock closed to hold it in place. Gelfoam may be used to help control bleeding.

Home care: Have the patient soak in a few inches of water in warm tub bid for the next two to three days. NSAIDs are first-line treatment for pain and inflammation. Wash (shower is best) the anal area after every bowel movement with soap and water. Post-operative opioids are relatively safe in small amounts with stool softener and increased fluids. Fiber regimen should be added after healing.

Antibiotics are not indicated.

Warn patients of residual skin tags and that scant bleeding is OK.

Plan colorectal follow-up care.

Contraindications and Cautions

Thrombosed external hemorrhoids are most effectively drained less than 48 hours after onset. Prolapsed/thrombosed internal hemorrhoids are not amenable to ED surgical drainage.

You should not complete this procedure on patients who are obese, who have breathing disorders or airway compromise, bleeding disorders, seriously systemic illness, rectal abscess, or who are hemodynamically unstable.

Patients using aspirin, Plavix, warfarin, or other anticoagulants should be approached with caution and possibly referred to a colorectal surgeon, although it is not an absolute contraindication.

A post-thrombectomy flexible sigmoidoscopy or colonoscopy based on the presence of associated symptoms and risk factors for colorectal cancer should be considered in patients over 40.

Have the patient increase his fluid intake. Steroid creams should not be applied until the incision has healed, and then should be applied twice a day for no more than seven days.

Supportive Treatments and ProphylaxisTopical analgesics can be used postoperatively. Topical corticosteroids and astringents can control itching and irritation. Avoiding constipation and straining with stool bulking agents and softeners are the best ways to prevent recurrence.​

Ultrasound may seem intimidating at first, but it is not a procedure out of your reach. Those of you still feeling shy about it should just play with it to increase your comfort level. It's OK to be early for a shift or to stay late figuring out the machine. Try using ultrasound on patients who will allow it and scribes who don't say no. It can't hurt, and it will make you a better and more knowledgeable provider.

We all know an "official" ultrasound is needed to confirm a suspected DVT, but what if you just need to know right away? Picture this: You are starting an overnight shift and are already 10 patients deep. Your 55-year-old patient with leg pain and unilateral leg swelling is waiting for an ultrasound, and it's going to be awhile. Your plan is to do some basic labs and obtain the official ultrasound to rule out a DVT. The patient has a few risk factors for DVT and a story to match. Why not test your bedside skills and see what you can see?

Bedside ultrasound for DVT is a great way to plan your night and your patient's future. You begin to ask yourself if you need to transfer this patient, probably let him go home, or admit him to the hospital. It's nice to know where your ducks are, so throwing the ultrasound on patients to make a decision from the get-go is imperative. Then you can order that official test. Why can't you do it, too? The good news is you can, and here is how.

The ProcedureBedside ultrasound with linear probe to detect DVT in lower extremityCollection of data, formal ultrasound, and admit/discharge plan

​The PauseWe want to draw your attention directly to our video. If you have been following our series on ultrasound, all you need to do is watch this and like magic, you have your answer. You can read the first four part of this ultrasound series on our website. (See box.)

Clinical Pearls and EBPThe best way to detect proximal lower extremity DVTs in the emergency department is to use a "modified 2-point compression technique that focuses on the highest probability areas, decreases the study time to less than 5 minutes, and provides similar sensitivity and specificity." (Acad Emerg Med 2000;7[2]:120.)

A "negative compression ultrasound study may safely delay the need for anticoagulation therapy" if a patient has a clinically suspected DVT.(BMJ 1998;316[7124]:17) Not only does bedside-provider ultrasound help determine the diagnosis and plan, the 2-point DVT compression examination has been "assessed in multiple randomized controlled studies and is well accepted when used properly with pretest probability assessments" (JAMA 2008;300(14):1653.) It's imperative you try it and expedite the care of your patient who need it most.

​Tip of the WeekAmie Woods, MD, a clinical ultrasound expert, has some tips if you decide to dabble in the artistry we call ultrasound. Dr. Woods suggests using the bedside ultrasound test to help make clinical decisions. Usually, following the common femoral vein to the mid thigh will give you the results you need. This can be a reasonable tool to diagnosis DVT if you can confirm the compressibility. It's important to note that this does not rule out superficial DVT. All superficial DVTs have the ability to form a true DVT and need formal outpatient follow-up or a repeat study. But this means it's possible for you to send patients home on high-dose aspirin therapy and schedule a repeat exam with a vascular surgeon. Formal studies are never a bad idea, but your steady hand can help predict the long-term outcome.

​This Father's Day, Emergency Medicine News would like to recognize a true leader in emergency medicine. James R. Roberts, MD, a distinguished professor and emergency physician, is one of the founding fathers of the specialty. Since 1972, he directly assisted in building the profession, paving the way for thousands of individuals who now call the ED their home.

Dr. Roberts was one of the first emergency physicians in the country, and he has taught tens of thousands of students over the years including physicians, fellows, residents, nurse practitioners, physician assistants, and nurses. His expertise is recognized worldwide, and his procedure textbook, Clinical Procedures in Emergency Medicine, is a staple in every ED, not to mention the global reach of his EMN column. (http://emn.online/INFOCUS-JR.) Dr. Roberts' clinical work in the ED and his toxicology expertise have helped saved the lives of thousands of sick children and adults.

Not only has Dr. Roberts groomed students and new practitioners, he has also taught many, including me, the art of the profession. It's not often you find his kind of intelligence anywhere, but when you do, it is rarely in his modest form. He manages to effortlessly balance his great intellect with a great sense of humor and wit that makes practicing emergency medicine rewarding, interesting, and fun.

I am truly lucky to call him Dad. He taught me everything from my ABCs in grade school to the ABCs of ED patients. He is a truly unique and dedicated soul, but he is, above all else, a caring person. Not only is he highly educated, he practices with feeling, intuition, common sense, and passion. His modest mentorship and enthusiasm for emergency medicine is contagious, in a good way.

This fall during the American College of Emergency Physicians Scientific Assembly in Las Vegas, Dr. Roberts will receive the award for Outstanding Contribution in Education. In nominating him for that award, Anthony S. Mazzeo, MD, wrote, "He has educated physicians worldwide on the nuances of all aspects of EM, from the mundane to the exotic, all with the charisma and erudite vocabulary that is undeniably 'trademark Roberts'. … Dr. Roberts remains a humble, modest, dedicated, and hard-working educator who would clearly never seek the recognition of this award. However, those of us who have worked with Jim and learned from Jim over the years feel this recognition is undeniably warranted."

Happy Father's Day to all the fathers of emergency medicine, and Happy Father's Day to my Dad, James R. Roberts, MD.

It's time to be fearless and embrace the true utility — and maybe implement a new policy in your ED — of ultrasound-guided intravenous (IV) line insertion.

Many physicians, NPs, and PAs already know how to place US-guided IVs, but we can help teach those who don't. Provider teaching can be in the form of real-time IV placement or a short 60-minute procedural training course open to all those who are interested. You can even use our procedural videos to help get you started! (http://emn.online/Mar16PP.)

We all know our difficult patient population includes prior IV drug abusers, obese patients, patients with chronic illnesses, and hypovolemia. Let's make the procedure less painful for them! No one is asking for our nurses to place central lines or diagnose a DVT using US, but basic understanding of US technology is not difficult and can be beneficial for the patient. A delay in establishing vascular access can result in a delay in the administration of a fluids and medications.

Patients frequently experience delays in diagnosis and initiation of treatment. Multiple attempts at attaining vascular access also result in frustration and a loss of productivity by the treating team. (Clin Pediatr [Phila] 2009;48[9]:895.) (Rauch, Dowd, Eldridge, Mace, & Schears, 2009). Nurses and technicians are more likely to establish a well-placed, working IV site once they can identify the veins and arteries on the screen. This could help speed up treatment for a patient who needs an 18 g needle for a CT scan to rule out a PE or a septic patient who needs resuscitation.

The PauseMake sure this particular procedure is already approved for immediate use. The emergency medicine technicians (EMTs) can use the US machine to insert IV lines in most hospitals, but in other institutions, RNs are allowed to do this without an order. And still, some facilities allow only a physician or midlevel to run the procedure.

The Approachn Inform patient of need for intravenous line.n Alert nurse and EMT team or place order for IV line.n Nursing or EMT team attempt standard IV insertion. A US-guided approach should be activated if IV placement cannot be obtained within two attempts. NOTE: Consider creating a standing order or policy for department to allow nurses to complete this activity on their own without waiting.n Regardless of who is initiating line placement, obtain the following items: appropriate-sized catheter (18 g is suggested), chlorhexidine prep pad, tourniquet, IV line set up or start kit with NS flush, sterile towel, and marking pen. Also obtain the US machine with linear probe, sterile US gel packets, US probe sterile plastic cover, sterile gloves, and any other equipment (i.e., culture bottles or lab testing tubes).n Obtain written or verbal consent for the procedure.n Prepare for US-guided IV placement. First, use the linear probe to examine the arm without a tourniquet. Attempt to locate deep and superficial veins for IV cannulation. Consider deep brachial veins and move the probe slightly higher up the bicep to look for deeper veins.n NOTE: Remember that arteries will be pulsating and veins will not. If you turn on the color indicator, arteries will also appear red and veins will appear blue.n Continue to look for veins by pressing down on the probe. Veins should be easily compressible. Add the tourniquet. Continue your search.n Once you have located the vein you wish to cannulate, use the marking pen to mark the site. Note the depth on the US machine so you know how far to advance your needle.n This is where it gets a little tricky. If you are confident that you can stick the vein without continuous US guidance, you can clean and prep the site and then insert the needle. At this point, you will be finished with the procedure.

If you are unsure, then you need to take this a few steps farther:n Clean the site with chlorhexidine.n Add sterile gel to the site on the arm you plan to cannulate.n Set up a sterile towel on side table, and drop your sterile needle onto it. You will use the towel later to wipe off any extra gel. It's good to be prepared.n Don sterile gloves.n Ask an assistant to open the US probe-cover packet. Grab it and ask the assistant to squeeze gel inside the sleeve of the US probe cover. Do not break sterility.n Have your assistant place the linear probe into the sleeve as you expand it over the full length of the probe and cord. Do not break sterility.n Place the sterile-covered probe onto the site you already examined.n Relocate the vein using your landmarks and markings.n Use the US-guided technique to watch your needle enter the skin and cannulate the appropriate vein.n Complete IV setup once the vein has been properly cannulated and the outline setup has been connected.n Clean off the arm with the towel to remove any extra gel or blood.n Complete the procedure by securing the IV line, drawing labs or cultures (if indicated), and flush the line with NS. NOTE: We often suggest that providers draw a 10 mL syringe of blood during initial placement, which can be placed in your sterile field prior to starting the procedure.

​Major Cautionsn If your patient is a frequent flyer and you know a line will be tough, try to use the US technique immediately, before completing two blind sticks.n Do not forget to remove the tourniquet when the procedure is complete.n Do not break your sterile field. You are cannulating a deep vein, and the potential for artery cannulation is possible.n Immediately remove the IV catheter, and add pressure to any site where arterial cannulation was inappropriately completed.n Consider US of the upper extremity to rule out DVT if a patient returns to the ED with arm pain after a deep vein cannulation and signs of DVT.

​Tip of the WeekFeel free to ask your administration if you can create a policy for US-guided IV placement and explain why it is beneficial for patient care (pain control, expedited testing etc.) and nursing autonomy. Consider offering to teach a 60-minute lab on US-guided IV insertion.

​Educational ConsiderationsUsing ultrasound for IV access requires training, and the literature is mixed. Physician training is incorporated into residency training with up to 16 hours of didactic and more than 100 ultrasound scans. It is suggested that "nursing and technician staff members train with at least one hour didactic with additional hands on training." (J Emerg Med 2006;31[4]:407.)

​PearlThe Emergency Nurses Association's policy supports US-guided IV placement by physicians, nurses, and techs in the appropriate setting. Read more about it at http://bit.ly/1iy4taJ.

Ocular ultrasound is a short and sweet procedure that could change your practice and greatly benefit your patients. It can actually be used to diagnose retinal detachment, which in the past required a referral to an ophthalmologist and often led to delayed therapy. Noninvasive and simple ultrasound techniques can be used on any patient of any age presenting with visual changes. The differential for visual changes with or without complete vision loss or blurry vision encompasses a daunting list. This is for you especially if retinal detachment is on your differential.

First, let's review the anatomy. Visual messages are sent from the retina through the optic nerve to the brain. Patients experience painless, unilateral vision loss, which may be permanent if for some reason the retina becomes detached, moves, or is pulled away from its normal position. Other problems, such as retinal tears or breaks, can cause brief vision loss and can lead to future complete detachment. ("Facts about Retinal Detachment," NIH, National Eye Institute; http://1.usa.gov/21P46bg.) Patients will complain of unilateral vision changes without other symptoms aside from blurry or cobweb vision or floaters (photopsia). Some say they even see black, which can be the last fatal phase of retinal detachment.

Do you have a history of uveitis, degenerative myopia, or other eye complications?

And most importantly, have you experienced an increase in the number of floaters, cobweb-like vision, or cloudy/flashy vision in one eye in the past few weeks or months?

If your patient said yes to any of these questions, it's time to break out the ultrasound machine and be prepared to look directly at the retina. Remember, a retinal detachment may occur at any age, although it is more common in those over 40 and Caucasian males. (http://1.usa.gov/21P46bg.)

The Procedure: Ocular ultrasound

Ultrasound-guided identification of retinal detachment using the linear probe

Prompt and appropriate follow-up with retinal specialist if defect found

Measurement of ONSD if concerned about elevated intracranial pressure

The Approach

Complete an excellent history and fundoscopic exam.

Obtain an ultrasound machine.

Put your patient in a supine position.

Engage linear probe (7.5 MHz or greater). Set the machine in B-mode and activate the "ocular" preset.

Place a clear Tegaderm over the patient's affected eye after he closes it. This will prevent the lubricating gel from getting into his eye. It also does not pull off eyebrows or eyelashes. Tell the patient thisprior to application, and that it prevents any foreign bodies from entering the eye or causing eye irritation.

Smooth out any air bubbles in the Tegaderm.

Add lubricating gel over the Tegaderm.

Darken the lights in the room.

Be prepared to use the probe in the transverse plane. The indicator should be pointing toward the patient's ear (i.e., you are looking at the left eye, the probe is held in the transverse or horizontal position with the indicator pointing toward the left ear).

Gently place the linear probe over the Tegaderm and adjust your depth to see the entire globe: the anterior and posterior chambers and ONSD. Identify all structures.

Locate the retina and determine if detachment has occurred. You will see a white line flopping around and waving gingerly at you on the screen. It looks almost like a streamer.

Pull off the Tegraderm to reveal a dry, non-irritated eye and complete appropriate follow-up. Immediately call for assistance if there is a detachment, and refer to ophthalmology.

Note: If you wish to measure the ONSD, it should be <5 mm. The provider should be concerned about elevated intraocular pressure if it is >5 mm. Studies have shown these two ailments have a direct clinical correlation. Start in the transverse plane when you measure. Measure the width of the optic nerve sheath 3 mm posterior to the retina and then "rotate the transducer clockwise to measure the ONSD in the sagittal plane, perpendicular to your first measurement. (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)

Compare both eyes.

Limit your examination of the eye(s) with the ultrasound and adhere to ALARA principle (as low as reasonably achievable).

This procedure may initially sound difficult and above your level of expertise, but once you see a retinal detachment on ultrasound, you will never forget it. Discovering a retinal detachment is as simple as turning on the machine, using your linear probe on the affected eye, and examining the globe and its structures.

The retina itself is usually a flat white thickened line, which lies securely among the tissues at the back of the eye. A normal globe itself will appear dark (the vitreous), and the retina will appear white.

A significant detachment will show the white retinal tissue flopping and waving around in the black area, close to its normal resting place. Sometimes, you may be able to identify PVDs or hemorrhages. PVDs are usually thinner and smoother than retinal detachments and are more mobile. Retinal detachments should also not extend to the ciliary bodies because of their anatomy while PVDs usually do. A retinal detachment should also not extend over the optic sheath. Retinal detachments will be thicker, white (hyperechoic) membrane-like structures with multiple folds and move with ocular movements. (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)

Keep in mind, your patient may still have a retinal artery occlusion (RAO) or spasms even if the retina appears normal. These patients may present with similar complaints of vision loss or changes caused by clots or blocked retinal arteries. The retina is starved of oxygen and nutrients and essentially dies and causes these symptoms. RAO may occur in patients who are symptomatic and without retinal detachment or who have a history of atherosclerosis. Final exam tip: You may see macular edema on your fundoscopic exam if you suspect RAO. RAOs can be treated with lasers, blood thinners, and treatments used for atherosclerosis.

Our retinal partners use a freezing treatment called cryopexy to fix the retina with lasers. They basically fuse it back in place. The majority of retinal detachments are treated successfully if identified quickly by the emergency department provider. Remember, the retina is at high risk for complications and requires an ophthalmologist's care.

Cautions

Don't push too hard on the probe. You won't need to apply much pressure at all if you use enough gel.

Use the bridge of the patient's nose or his forehead to stabilize your hand.

Use a dark room.

Keep it clean. Use the Tegaderm approach.

Obtain a fundoscopic exam prior to the ultrasound exam.

Test the visual acuity.

Use the "freeze" button on the machine to hold your image on the screen so you can complete the identification and measurements of the globe's structures. This allows you to look longer and closer without leaving the probe directly on the patient's eye. It also allows you to measure the ONSD accurately.

If you suspect ruptured globe and see that while doing your exam, stop and call the specialist immediately. Refrain from using tense pressure on the orbit.o Warm lube? No way, this is not a fetus! Chilling the lube actually allows you to complete a better exam because it causes increased viscosity and "allows the gel to stack easily." (Point-of-Care Ultrasound. Philadelphia: Saunders/Elsevier; 2015.)

Retinal detachment and PVD are difficult to distinguish, but patients may be more likely to say they see floaters as opposed to having vision loss if suffering from PVD.

Procedural Pause Overachievers

If you really want to impress your ophthalmology colleagues, you can also measure the blood flow to the retinal artery based on a very simple equation related to the diameter measurements and blood flow seen on the ultrasound exam. If you want to know more about this, check out this great Austrian study by Droner, et al. (Curr Eye Res 2002;25[6]:341; http://bit.ly/25snrDM.)​

BONUS VIDEO: Watch Dr. Amie Woods' TEDx talk, "This is What's Making Me a Better Doctor," for her experience with ultrasound and a patient with a life-threatening condition: http://bit.ly/1VucDAx.

Are you ready for summer? That means more bare feet, flip-flops, and the potential for foreign bodies of the foot and toe. We will continue to highlight tools and tricks to help you master soft tissue foreign body removal in the emergency department. A refresher on the basics of ultrasound is available in our blog post from last month: http://emn.online/1UGtduz.

Foreign bodies of the toe or foot are common presentations in emergency departments, and one way to determine the size and shape of retained superficial foreign bodies is to use ultrasound and the linear probe. This simple technique may help you locate certain items quickly and more efficiently than just radiographs alone. We do, however, suggest obtaining plain A/P and lateral films of the foot or toe prior to completing this procedure.

Keep in mind, only radiopaque foreign bodies (metal, glass, pencil graphite, gravel, and stone) will show up on plain film radiographs. All glass is radiopaque, and only small size limits its radiographic detection. Other objects, especially wood, plastic, dirt, cloth, aluminum, toothpicks, and small bones, are radiolucent and usually cannot be seen on plain films. Hidden retained wooden items guarantee a subsequent infection, which may cause extensive problems such as repeat visits, abscess formation, and surgeries, but studies show ultrasound is a useful tool to detect their presence. (J Emerg Med 2002;22[1]:75.)

Foreign bodies are often missed on the initial exam even if a plain film radiograph is obtained. A retrospective review looked at 200 consecutive patients with foreign bodies in the hand, 95 percent of whom had wood, glass, or metal in their hand. Their follow-up lasted for approximately six weeks. Some of the injuries were treated immediately while others were removed up to 20 years later in the office or in the emergency department. Interestingly enough, providers initially treating patients missed 30 percent of the foreign bodies even when a plain film radiograph was obtained. Metal was visible in all of the radiographic studies obtained, glass in 96 percent, and wood in only 15 percent. (Am J Surg 1982;144[1]:63.) Because ultrasound can assist with finding radiolucent objects, this simple intervention may help you successfully remove these objects on initial presentation before they can cause additional problems.

The Plan and Approach

< Obtain a radiograph of problem area.< Use bedside ultrasound to locate abscess and foreign material.< Anesthetize the problem area.< Open, drain, and explore abscess.< Wash it out.< Remove any additional foreign bodies with tweezers or hemostat probing.< Pack the wound if indicated. Do not suture closed!< Apply a dry, bulky dressing.< Follow-up with podiatrist in 48 hours.

The Pause

Anytime you plan to remove superficial foreign bodies in the skin, be sure to clean the area well and irrigate the problem area. This will ensure proper cleaning and debridement.

The Procedure

< Obtain plain A/P and lateral films of the affected area.< Place the patient in a supine position.< Elevate the foot onto tightly rolled towels as needed for positioning. Place several under the ankle and some under the patient's knee. Note: Pillows are not helpful because the foot rolls to the middle and is not properly elevated.< Set up the ultrasound machine. Use the linear probe at a depth of approximately 2-4 cm (depending on superficiality of the object) and adjust the gain as needed.< Locate the pocket of pus or fluid as well as any retained foreign bodies.< Clean the entire affected area and associated areas with Betadine or chlorhexidine.<Use a 22 or 25 g needle to inject 1-2 mLs of 1-2% lidocaine (usually with epinephrine/bicarbonate) to the affected area. Be sure to stabilize the foot or toe to avoid sticking yourself.< An option is to use a blood pressure cuff on the calf to obtain a bloodless field.< Use a tourniquet if you are working on a toe. Do not forget to cut it off when your procedure is completed.< Clean the area with additional prep to ensure a clean site.<Depending on the site of penetration, make a linear (or horizontal) incision using an 11 blade scalpel. Make sure the incision is large enough to allow probing and drainage of the abscess.< Probe the area for the foreign body, feel for and look for the foreign body, and remove and deloculate the abscess.< Use the ultrasound guidance (sterile covering) to continue examining the area for any retained foreign bodies.< Wash out the wound with simple irrigation. This may require several attempts.< Avoid jet irrigation because this may push foreign bodies farther into the skin.< Tap water irrigation is fine, even in children. (Ann Emerg Med 2003;41[5]:609.)< Insert packing as needed. Packing may be indicated if the wound is bleeding. Note: Best to avoid suture closing.< Packing is usually not required, and the wound can be re-examined in two days.< Place a dry, bulky dressing over the wound and assist the patient with crutch training. Have the patient elevate the foot several times a day.< Did you make sure the tourniquet was cut off?< Tell the patient to follow up with the podiatrist or the ED in 24-48 hours for wound re-evaluation.<​ Consider adding antibiotic coverage for Pseudomonas for more complicated wounds, infected cellulitic-appearing abscesses, diabetic, HIV+, or immunocompromised patients.

CautionsBe careful not to cause further damage to this already irritated area. The thin skin around the toe and foot can be easily destroyed with excessive irrigation, probing, and incisions. This may cause increased scarring, pain, deformities, and distress to the patient.

Remind the patient that elevation willhelp with pain, swelling, and overall healing. Crutch use will assist with decreased bleeding and pain. Motrin or Tylenol are acceptable treatments for post-procedure pain, but some patients may benefit from a short course of stronger pain control such as Norco or Percocet. Use at your discretion.

Not all abscesses need packing. It is suggested that bleeding wounds do, and simple, smaller abscesses do not. Often, it is not what you put in it, but what you take out of it. The literature is still mixed on final recommendations for wound packing. It was used in this particular case and removed in less than 48 hours. It helped control the bleeding and keep the wound open for drainage.

Notes on packing and pain: Patients who have packing placed often have more pain and need medications like ibuprofen and other narcotics. (Acad Emerg Med 2009;16[5]:470.) It is uncertain if the risk benefit of packing is needed for these patients, and it may even delay healing, increase complications, and create a need for secondary interventions.

One study found packed wounds may result in delayed wound closure, with closure times basically doubled. They found the rate of wound reoccurrence, however, was equal. (Am J Emerg Med 2011;29[4]:361.) Update the patient's tetanus shot if it has not been done in the past 10 years. (Am Fam Physician 2007;76[5]:683.)

Do I give antibiotics? Not usually. The treatment for these injuries is to remove the foreign body and drain any abscess associated with the item. Give some thought to the patient's presentation and current state, especially because these are considered penetration injuries. Continued infected or irritated sites require you to look for more foreign bodies. Risk of infection increases with prolonged foreign body retention, dirty wounds, and medical history of diabetes, HIV, etc. The use of prophylactic antibiotics is not typically recommended in non-bite wounds (even with foreign body presentation) or simple wounds. (Am J Emerg Med 1995;13[4]:396.) No hard and fast rules apply for treatment unless you suspect Pseudomonas as a potential culprit. Dog or cat bites with retained teeth should be placed on Augmentin.

Antiseptic agents such as hydrogen peroxide and povidone iodine should not be used, especially on the packing in the wound. These can be toxic to tissue and may slow healing times. The debate is still out about chlorhexidine. (Am J Dis Child 1987;141[1]:27.)

It is best to tell the patient and document on the record that more foreign material may be in the area even though you removed a foreign body, and there are no guarantees that you got all of it. If prolonged pain or infection occurs, additional foreign bodies may be present. When all else fails and a foreign body is still considered, a CT scan should be ordered.

Tip of the Week from Lawrence Stern, MD, in Fairfax, VA:Packing most wounds (post-abscess drainage) is simply not necessary based on my experience and studies. One of the best times to pack a wound is if it is a very large incision or if the abscess cavity is bleeding. The majority of the time, packing is not required, even with larger abscesses. Packing will, however, keep the wound open and control the bleeding when indicated.

We know we don't need to remind you of the sheer power of ultrasound and its usefulness in the emergency department. Not a day goes by that the ultrasound isn't wheeled to the patient's bedside for a FAST exam, a quick gallstone check, or to rule out retinal detachment. The uses for ultrasound are endless.

The first part of this series looks at the basic functionality of the machine and how to look for foreign bodies in the extremities. Even if you choose not to adopt this practice, it may inspire you to learn more about the uses of ultrasound.

This is by no means a full online course! We don't intend for this blog to minimize the skill and acquired talent because it does take time, education, practice, and energy to learn. With that being said, we do not expect you to be radiologists nor do we anticipate your being experts at using the machine. We do hope, however, you will be skilled enough to know how to look for pus, fluid, or foreign bodies with a quick exam.

You can learn a few ultrasound techniques that are uncomplicated and useful. This first video is meant to motivate you to practice. Not only will this newly acquired skill shorten your time spent digging, but it will impress your patient and shorten your door-to-dispo times. Who wouldn't want to do the best thing possible for her patient? Plus, you will see the wonders of ultrasound and possibly be inspired to learn more.

It is imperative that you use the resources you have and collaborate with all partners in your field whenever possible. Emergency medicine should never be a one-(wo)man show. It's yet another reason to make friends with the radiologists down the hall; they can teach us a thing or two.

​The Approach

n The power button, the gain button, the depth, and the colors

n Basic understanding of the ultrasound machine and images you are seeing

Dr. James R. Roberts & Martha Roberts, CEN, ACNP, bring you tips, tricks, and pearls for how to diagnose and treat a mallet finger. Everything you need to know is in this video. Click here to watch the video.​

Every new advanced nurse practitioner, physician assistant, or resident gets his fair share of complex emergency department procedures during training. Seasoned providers, however, are just as excited to place a central line in a septic patient, LP a "rule-out meningitis," or swiftly fix a nursemaid's elbow.

This month we hope to remind you of a few sweet and satisfying procedures that take only moments to do. Your skill in completing these procedures is imperative. Not only will you amaze your patient, but you'll shorten your door to dispo-time.

The Stye

The stye is a nefarious character with an agenda. It starts off by slowly enlarging over the patient's lid, and it can consume other portions of the face if not treated appropriately. Patients may present to the ED on the fifth day or later when the enlarged lid starts to impair their vision. Occasionally, patients have associated facial swelling, tenderness, or even a preseptal cellulitis. Distinguishing the signs of these complications is imperative for proper treatment. It may be difficult to discern the emergent eye from the urgent eye from the "it-can-wait" eye. You will feel confident about draining an eye lid abscess after reading this post, and you can add one more magic ace to your deck.

The Approach

Identification of stye (or hordeolum)

Evert the lid to look for the pus collection

If pus is readily seen, incision and drainage of stye

Correct outpatient treatments and aides

Ophthalmology follow-up

The Pause

A stye, or hordeolum, is an eyelid abscess that is internal or external. They are erythematous, tender, and swollen collections of pus that are also typically bacterial infections. Styes usually point externally and progress in size over time, and touch and blinking can exacerbate the pain.

Styes usually occur when a hair follicle or gland becomes blocked or irritated. Patients with chronic blepharitis may also experience more frequent occurrences of styes. Just like any other abscess, the treatment of a pus-containing stye is incision and drainage (I&D). Don't attempt I&D if no pus can be seen. Rather, advise warm soaks for a few days to see how it progresses. We also urge patients to do warm water (not scalding) washcloth soaks five or six times a day for 15 to 20 minutes each for several days after I&D. The best way to do this is to fill a sink with hot water, place two washcloths into the water, wringing one out and applying it to the eyelid. When it cools, change the cooled cloth for the hot one in the sink. Alternate the cloths so one of the hot compresses is on the eyelid for about 20 minutes.

Health care professionals will often ask patients to apply topical ointments, such as erythromycin or triple antibiotic ointment ophthalmic ointments. New studies and evidence-based practicing ophthalmologists, however, suggest using neomycin instead because of the resistance to erythromycin.

Some people are sensitive to neomycin, so a generic (and inexpensive) alternative is polysporin ointment such as bacitracin-polymyxin. Other ointments such as tobramycin and gentamicin [HL2] aminoglycosides are bactericidal antibiotics that will inhibit bacterial protein synthesis, but they do not work as well as they used to. These drugs used to be very effective, but certain bugs such as Pseudomonas aeruginosa and some Staphylococcus aureus have formed a strong resistance. UpToDate suggests that most styes are caused by S. aureus. Randomized controlled trials regarding antibiotic ointment treatment are lacking. UpToDate does suggest that topicals "do not aid in promoting healing," although most clinicians will still prescribe antibiotic ointments. (http://bit.ly/1K2Khoz.) Clinicians may occasionally need to prescribe treatment for styes with antibiotic ointments for patients with chronic blepharitis.

It is important to talk to patients about the risks and benefits and the cost for treating straightforward styes in an otherwise healthy, well-appearing patient without a preseptal cellulitis. Patients should first attempt warm soaks prior to an ointment regime or just prior to application. Furthermore, you need to leave the corticosteroid drops to the professionals and refer patients to be seen in two to three days for a full exam in the office with a working slit lamp.

One More Pause

Knowing the language when it comes to eye diseases and issues is really sexy. It feels good when I can tell an ophthalmologist I see no cell and flare and no Seidel sign[HL3] . We want to make sure you can talk shop about eyelid abscesses. The difference between the stye and the chalazion is that styes can turn into a chalazion, and these need to be excised and drained by an ophthalmologist. For a great video of this very procedure, we urge you to watch Dr. Mel Herbert get his eyelid treated for chronic stye turned to chalazion here: http://bit.ly/1RdLAsC.Dr. Herbert reminds us that chalazions are inflammatory, sterile, chronic lesions (more than two weeks) of eyelid gland. He advises to try warm compresses and seek the ophthalmologist if all else fails.​

Take out any contact lenses and tell the patient to refrain from wearing them for at least two weeks.

Drop two to three drops of tetracaine into the patient's affected eye. Let him hold a tissue under his eye after you place the drops. This gives him something to do, and it helps him blot his eye as it tears from the medication.

Examine the eye thoroughly. Evert both lids. Check for foreign body with staining and the Wood's lamp. Examine the pupil reaction and light sensitivity.

Put the 25 g needle onto a 3 mL syringe. This will allow for greater stability and control of the fine needlepoint.

Place the warm compress over the eye for approximately 30 seconds to clean the eye and prime the abscess for drainage.

Use the 25 g needle on the 3 mL syringe by entering the stye horizontally (not vertically) over the area of maximum tenting.

Gently squeeze the lid to extract all pus.

Promptly apply another warm 4x4.

Allow the patient to hold the 4x4 on his eye while you complete paperwork.

Have him follow up with ophthalmology in two to three days.

One last trick for the more anxious patient: Prescribe a single Valium 5 mg tablet at bedtime [KA4] to ensure a restful night's sleep and eye rest. This is also helpful for those who present with corneal abrasion.

Do not blindly incise the swollen area of the eyelid if no pointing pus pocket is identified. Drainage of the superficial pointing abscess is usually very easy and curative, but not all swollen eyelids contain a simple stye.

Evert the eyelid to identify the area when pus has accumulated and where the abscess is pointing. It's usually on the lid margin.

Do not be afraid to get blood or pus in the eye. Use tetracaine to numb the eye to avoid the foreign body sensation during the procedure. Irrigate the eye with gentle normal saline or other eye wash post-procedure.

Immediately apply a warm compress post-procedure.

Consider suggesting artificial tears for daily use to help with dry eye complaints.

Do not give ointments or antibiotics to patients with simple, straightforward styes. Consider reserving oral antibiotics for those who have a facial cellulitis or if you are concerned about preseptal cellulitis.

Doing a CT of the orbits is highly recommended if preseptal or septal cellulitis is on your differential.

Consider other diagnoses if the eye appears red and inflamed and the abscess is not that impressive. Are you missing shingles? Is there a Hutchinson's sign[HL5] ? Did you look for dendritic lesions?

Is the patient HIV positive or have a transplanted organ, hepatitis, diabetes, or a previous nonhealing infection? Consider ophthalmic ointments and oral antibiotics.

What about pain control? Acetaminophen and ibuprofen are fine choices if there are no contraindications.

Lower lid styes over the lacrimal gland should not be drained in the ED and need immediate ophthalmic follow-up. These typically will need oral antibiotics; consider doxycycline or cephalexin.

Are styes contagious? Generally not, but we must encourage patients not to rub their eyes because this can cause corneal abrasion and worsening infection.

If you consider the abscess to be a chalazion and it has already been drained in the past month, do not drain it again. It will only cause the patient more pain and it will reaccumulate. It may also cause worsening scarring. Refer these patients to ophthalmology in the morning. The 2 am wake-up call is not necessary.

Tip of the Week

Eye drops and ointments are among the worst offenders when it comes to cost. Erythromycin and triple antibiotic ointment are roughly $15-$20 per gram, but others can truly break the bank. Vigamox is about $150,) and TobraDex is $200, and they may prevent patients from filling the prescription. These big guns aren't typically indicated for a simple stye. It is imperative that you understand the treatment and antibiotic course for all ophthalmic conditions. The ocular stye may be one of your most frequent offenders, so keep in mind that triple antibiotic ointment is affordable and most likely an effective treatment. The true treatment remains: I&D, possible antibiotic ointment, and wound check in 48 hours if not better.

This is the third and final part of our series on foreign bodies and fluoroscopy. Click here for part one and herefor part two.

This month, we walk you through a step-by-step guide with bonus video footage to aid in your technique. This progressive procedure is absolutely significant to your practice, and we hope you all get a chance to try it.

The Approach

nIdentification of foreign body on plain film or ultrasound

nSaphenous or posterior tibial nerve block

nEnlargement of the wound or entrance site using incision or skin cutting

Are you prepared to get leaded up? You need to wear lead protection while doing this procedure. Be sure to remove any excess clothing or equipment before starting, and wear upper and lower lead in the radiology testing area (or even if you are using the portable C-arm). A thyroid protector is always suggested. If you are pregnant, we suggest opting out of performing the procedure, although studies have shown it is safe as long as you are properly covered. The guidelines for lead wear are standard per your facility. Most lead coats range from seven to 15 pounds, depending on the type and the amount of surface area requiring coverage.

The Procedure

nObtain radiographs of the affected area. The plantar portion of the foot was involved in this case so we obtained initial lateral and AP films of the foot. (NOTE: If the foreign body is known to be plastic or wood, fluoroscopy may not be a suitable choice for removal.)

nContact the radiology tech post-identification of the foreign body and inquire about the C-arm. Occasionally, this can be taken to the bedside, and other times it must be used in the radiology treatment area. (NOTE: You will have already checked your department policy. Do not try to sort this out in real time.)

nOrder continuous fluoroscopy in your EMR. For those of you still using paper, an order is required either way. You also need to document indications and alternatives for billing purposes.

nA local injection can be used, but often may not as effective as a full block.

It is important to know the approximate (if not exact) location of the foreign body because lower extremity blocks have specific areas of innervation. The nerve block is highly favored with additional anesthesia added to the site if needed.

nConsider using LET in the affected area for additional anesthesia. This can be applied in triage or prior to going to the treatment area.

nWrap a sterile towel around the ankle. This will help you move and reposition the ankle and foot while you are involved in the sterile procedure.

nPosition the patient in a supine position. As stressed in the past, positioning is half the battle and can make or break your procedure. Provide comfort for the patient with pillows or padding, use adequate lighting and height of your workspace, and have the nurse administer pain medication as needed. This allows for proper visualization, inspection, and timely management. (Emerg Med Clin North Am 2003;21[1]:205.)

nShield your patient with proper lead attire.

nPosition the C-arm appropriately over the affected area. (See video for actual positioning techniques.) The technician can help guide you and start your “exposure clock.” They are excellent resources during the procedure, and we suggest you check in with them often by asking how much time you have left.

nUse the same pen to act as an identifier for placement when using the scout shots to locate the FB. Mark the area on the foot.

nMake an incision over the area of interest with an 11-blade scalpel. Directly visualize the area without any probing to see if the object is visible and removable.

nIf not visualized, shoot another scout shot to determine depth of the foreign body while inserting your hemostat or forceps. This is when the continuous fluoroscopy may be of most help. As you approach the object, you will be able to see it in real time and localize it.

nOnce localized, remove the foreign body with hemostat or forceps. Tweezers should NOT be used because they do not close fully around most metal or glass objects.

nIrrigate the area. Large volumes should be considered, 300-500 mL. You must remove all foreign body material to avoid infection. Consider using a 10 mL syringe with splashguard to forcefully inject irrigation fluid. With that being said, application of “povidone-iodine solution, hydrogen peroxide, or detergents to irritant solutions should be avoided because of their cytotoxic properties and lack of significant bactericidal action.” (Ann Emerg Med 1999;34[3]:356.)

nWe also suggest using tap water because it is cheaper and creates less waste. It is also just as effective. (See tip below.)

nDepending on the incision you have made, you may want to consider closing the area with loosely approximated sutures. This approach is controversial and should be discussed with a podiatrist. If it is a small incision, no closure is needed, and a bulky dressing, cast shoe, and crutch should be used for a week to 10 days. Crutch or walker use is important because it will help relieve the pressure on the site. It is also important to encourage the patient to rest the extremity.

nAntibiotics: Yes for diabetics. We suggest staph and strep coverage with a cephalosporin such as Keflex. If the patient has a history of MRSA, you may want to consider culturing the site if it is an old, infected foreign body. One dose of IV Invanz or Ancef may also be considered. You must also consider coverage for Pseudomonas, so adding Cipro may be a solid choice.

nConsider the indications for foreign body removal first. Is there neurovascular compromise? Evidence of infection? Is it causing a cosmetic deformity? If it is causing a functional impairment or chronic pain or if the patient requests it, you should be gearing up to go to fluoro.

nIf the patient has none of the above and would prefer the specialist, consider referral at that time. Also consider signs of sepsis or bacteremia if the site appears cellulitic or more extensively compromised.

nConsider patients with diabetes, HIV, PVD, or other immunocompromised disorders to be delicate, and treat them with prophylactic antibiotics.

nContraindications include deep embedding, neurovascular compromise, poor or inadequate information about the foreign body, and risks for severe bleeding (i.e., bleeding disorders, medications). These issues should be considered high-risk, and the foreign body may best treated in the operating room or by podiatry directly. (Emerg Med Australas 2013;25[6]:603.)

nSet the patient up for success at the start. Many patients have expectations that the foreign body can easily be removed without much damage or complication. This might be the case, but sometimes it is not reasonable. Discuss risks and benefits with the patient upfront and why or why not the procedure should be completed.

nHave the patient sign a consent form with the risk-benefit discussion documented, and send a copy of that form home with them. Your paperwork should also include names of follow-up personnel, expected recovery course, signs and symptoms of infection, and the potential for retained foreign body. Nerve damage is also a concern, and should be discussed with the patient every time. Proper dressings, wound care technique, and extremity care should also be discussed ad nauseum.

The American College of Radiology recommends that your consent form state:

“Before the proposed procedure is performed, the following will be explained to the patient or, if the patient is unable to provide consent, to the patient’s legal representative:

“a. The purpose and nature of the procedure or treatment.

“b. The method by which the procedure or treatment will be performed.

“c. The risks, complications, and expected benefits or effects of such procedure or treatment.

“d. The risk of not accepting the procedure or treatment.

“e. Any reasonable alternatives to the procedure or treatment and their most likely risks and benefits.

“f. The right to refuse the procedure or treatment.” (American College of Radiology. ACR-SIR Practice Parameter on Informed Consent for Image-Guided Procedures. Resolution 39, 2014; http://bit.ly/1II3ror).

nMake appointments in real time for patients whenever possible.

nCaution (even possible contraindication) the use of this procedure in children. The risk of a “stochastic injury later in life is elevated for pediatric patients who have a longer projected life span and are more radiosensitive in the first decade of life than are adults.” (Pediatr Radiol 2002;32[10]:700.)

Possible Limitations

Not all procedures are perfect, and many times there are simply not enough data to support their everyday use. Two physicians used a mini C-arm to image foreign bodies in small blinded, randomized control in-vitro study. The physicians used five types of foreign bodies of different densities: metal, gravel, glass, wood, and plastic. The foreign bodies were placed into 50 of the 100 chicken legs. The blinded investigators imaged the legs and determined the presence or absence of foreign bodies. The results showed that although radiographic “imaging located 100 percent of metal, gravel, and glass, plastic and wood could not be consistently detected (sensitivity 0.4, specificity 0.6).” (Pediatric Emerg Care 1997;13[4]:247.) This may conclude that the mini C-arm can detect some foreign bodies but not all. Further clinical trials would help determine whether the procedure is truly necessary.

Foreign body of the foot removed. (Photo by Martha Roberts)

Additional Clinical Pearls

nUnprotected individuals working “24 inches (70 cm) or less from a fluoroscopic beam receive significant amounts of radiation, while those working 36 inches (91.4 cm) or greater from the beam receive an extremely low amount of radiation” (J Ortho Trauma 1997;11[6]:392.)

nHand and wrist radiation exposure is an identifiable concern because they are uncovered during the procedure. There is little information available on this specific area, but typically the hands do not eagerly absorb radiation.

Jim weighs in: The use of fluoroscopy is an individual choice. Some practitioners are unfamiliar with it, and some hospitals have strict requirements regarding users. The best way to get introduced to the procedure is to watch an orthopedic surgeon or podiatrist do it first. Then, see one, do one, and teach one.

Martha weighs in: Without a doubt, there will be initial push back from your facility concerning your capability to perform this procedure. Talk it out. Your scope of practice allows you to complete this type of intervention with assistance from your radiology team. You have the skills to read and interpret radiographs and remove foreign bodies. The problem is that you need a radiologist and technician to be your ally. Some of the radiology technicians require a radiologist to be at the bedside shooting the continuous fluoroscopy while you do the procedure, and that is just a protocol you need to follow. If this is your house procedure, then do it. There is no reason the radiologist cannot pop over for a five-minute procedure, and help you get set up.

Just have an open and frank conversation about the procedure and why it will be the best for the patient. When you put the patient first, it leaves little room for argument and muscle-flexing. Then again, if your in-house radiology chief flat-out states you cannot perform the procedure, then consider calling podiatry. Finally, if you are pregnant or simply do not want any more radiation exposure than you have already had in this lifetime, consider ultrasound or referral. We can’t all be Superwoman (or man)!

Welcome back to our series on foreign body and fluoroscopy. If you’re new to the series, catch up on part one at http://emn.online/1lb0SAI.

Why is fluoroscopy worth investigating? A group of Chinese interventional radiologists looked at eight years’ worth of data using percutaneous fluoroscopically guided removal (PFGR) of foreign bodies in soft tissues. The 2009 study looked at foreign bodies in the skin from one week to 10 years. Ninety-four percent of the 346 foreign bodies were removed without any serious complications. The removal time ranged from 30 seconds to 20 minutes, but the mean was one to six minutes. Set up, transport, and communication with specialists can add more time to your procedure. The technique is very effective and important to consider. The savvy practitioner may well conclude PGFR of foreign bodies in the soft tissue under fluoroscope is safe and effective. (J South Med Univ 2009;29[12]:2504.)

Another recent study analyzed the amount of radiation received by orthopedic surgeons during fluoroscopy procedures. (J Clin Diagn Res 2015;9[3]:RC01; http://bit.ly/1WKNIYG.) The authors looked at 12 right-handed male orthopedic surgeons in a three-month prospective study and their radiation exposure measurement (with adequate protection measures in all procedures) using C-arm fluoroscopy. Each surgeon used five thermoluminescent dosimeter (TLD) badges, which were tagged at the neck, chest, gonads, and wrists. The procedural and operative time was recorded, and researchers obtained the exposure dose of each badge. Mean radiation exposure to all the parts of the badges were within permissible limits, and a significantly positive correlation between exposure time and dose was seen for the left and right wrists. The authors concluded that the total amount of radiation exposure during fluoroscopy did not exceed the recommended levels.

We know you are hungry for evidence-based data so let’s get rid of this sacred cow once and for all. Sterile isotonic saline can be used as the choice for irrigation of wounds and soft tissue. Tap water, however, is completely acceptable. Numerous studies comparing the two show no significant increase in the incidence of infection. (J Accid Emerg Med 1997;14[3]:165; Ann Emerg Med 1990;19[6]704; Acad Emerg Med 1998;5[11]:1076; Am J Emerg Med 2002;20[5]:469.)

Many providers prefer an ultrasound-guided technique for most or all of their procedures. Many types of foreign bodies could be easily detected using US, according to a study by Gooding, et al. (J Ultrasound Med 1987;6[8]:441.) Some of these materials include but are not limited to glass, metal, wire, and wood. The US-guided approach, according to the authors, also “pinpointed the surface beneath which the foreign bodies lay and localized all precisely as to depth from the surface.” Simple detection of the foreign body is important, but precision is even more poignant. Misguided views of the object could lead to increased tissue damage, blood loss, and an increased risk of complications.

Fluoroscopy is simultaneously a useful and dangerous tool. If not used properly, this radiographic expedition will do harm to you and your patient. We are not trying to turn you all into radiologists or force you to do an interventional radiology rotation; we simply want to broaden your horizons. Plain radiographs reveal many things including broken bones, calcifications, and our topic of interest, foreign bodies. Fluoroscopy is the art of using serial x-rays to obtain a real-time view of a structure, dislocation, or object. It is a useful tool in the field of medicine, but if there is any doubt that the procedure is not appropriate, then don’t do it. Consider calling your radiologist and ask him to be present if he has the time.

Join us next month (and next year!) when we present the final part of this series with a step-by-step video and guided approach.

How many times have you wasted at least 30 minutes (if not more) digging around in a patient’s foot to remove a sewing needle or piece of metal or glass? Or maybe the question is, how many of you have immediately referred the patient to podiatry because foreign body removal isn’t an ED procedure?

Foreign body removal may not be emergent, but it can be urgent. Items left in the skin can cause complications and should be removed whenever possible to decrease risk of infection or other future issues.

Foreign body of the left foot in a 56-year-old woman.

The ED is the right place to do any and all procedures under the constraints of your medical license and hospital policies. Often times, specialists can complete procedures in-house or with a prompt follow-up appointment. Other times they are unavailable, in surgery, or too expensive, so you need an alternative plan. Patients only want to make one stop, especially if they are without health insurance, fiscal means, or a home. Then again, you could do this procedure for just about anyone and feel confident about it.

First, we must pause and discuss one extremely important recommendation that comes directly from the American College of Radiology (ACR). The 2013 technical standards for using fluoroscopy are specific and detailed for a reason. Radiation exposure is a big deal, and it can have lasting, catastrophic, and stochastic effects on patients, especially children. Your department must have a conversation and protocol in place about fluoroscopy procedures, and you need to be familiar with fluoroscopy limitations, expectations, and other requirements.

The ACR guidelines state, “Each facility should have a policy for granting fluoroscopic privileges to all physicians who perform or supervise fluoroscopy. Local credentialing and privileging processes should include review of training records and of procedures that use fluoroscopy to determine that the physician is both properly trained and qualified in fluoroscopy. Physicians must comply with all applicable state and federal laws and regulations, and with institutional policies and procedures for fluoroscopy licensure or certification.” (http://bit.ly/1MWRZDW.) You should be able to rely on your radiology team, including bedside technicians and chiefs of staff to be up to speed when it comes to these rules.

Large C-arm in radiology treatment area.

ED providers can use fluoroscopy as long as they work with radiologic technologists or radiation therapists who have received formal training in radiation management. The 2013 guidelines also suggest that “those assisting with fluoroscopy for fluoroscopically guided interventional procedures should undergo a formal authorization process, administered by the facility.” (http://bit.ly/1MWRZDW.) The only way the radiology technician can assist you, however, is if there is direct supervision, but it does not mean “the physician must be present in the room where the procedure is being performed.” (http://bit.ly/1MWRZDW.)

Finally, as far as direct supervision is concerned, the only exceptions are “for registered and licensed radiologic technologists or radiation therapists who perform fluoroscopy only as a positioning or localizing procedure,” which is exactly the procedure you are going to complete. Fluoroscopy must be performed under the direct supervision of a physician who meets specific qualifications. These procedures also must have “prior written approval by the medical director of the appropriate department or service, and there must be written authority, policies, and procedures for designating technologists who perform such procedures.” (http://bit.ly/1MWRZDW.)

Evidence-Based Practice Pearl

Many studies elaborate on radiologic beams and fluoroscopy, and it’s important to know your risk, the patient’s risk, and what to do during your procedure. The radiology technician and the radiologist are excellent resources and should be well trained to know how much exposure is too much and help to keep you in check in the work area. They should be the main person in charge while you do this procedure. Don’t spend more than five minutes doing continuous fluoroscopy, and don’t use fluoro if you do not feel comfortable with your radiology team. Keep in mind that continuous fluoro uses far less radiation at lower levels than radiographs. The dose makes the poison, and radiation dose depends on many factors, including the type of examination, patient size, equipment, and technique.

The bottom line: The ACR recommends receiving only 6,000 mrem/year from occupational exposure. International standards suggest 5,000 mrem/year for those who work around radioactive material. A jet plane exposes you to 0.5 mrem/hour. A chest x-ray gives you 10 mrem, a plain lumbar spine plain radiograph 600 mrem (lumbar series). A CT of the abdomen pelvis gives you about 1,000 mrem. Finally, a single x-ray of the lower extremity is 0.5 mrem. This means, if you use continuous fluoro (at the lowest level used by the radiology team) for five minutes (with one shot/second), your total exposure would be approximately 150 mrem.

Also take into account the direct exposure your hands receive during this procedure (if they remain under fluoro), which is dependent on the operator and extremity placement. Consider using intermittent or “pulse” fluoroscopy instead of continuous. The lower the exposure time, the lower the exposure dose and the radiation side effects, of course. (J Clin Diagn Res 2015;9[3]; http://bit.ly/1WKNIYG.) Radiation safety precautions should be taken and “exposures regularly monitored with at least one dosimeter for monitoring the whole-body dose.” Radiation safety programs should also be routinely conducted. (J Clin Diagn Res 2015;9(3); http://bit.ly/1WKNIYG.) The American Nuclear Society offers more about your estimated annual radiation dose. (http://bit.ly/1Ojy3y9.)

Radiation should not be taken lightly, so be prepared when performing this valuable procedure. Fluoroscopy and understanding its use is essential to your practice. After reading this series, create a stronger relationship with your radiology team and try it.

Our series on joint care has given you a basic overview on knee arthrocentesis. Typically, it is not necessary to have an orthopedic consultant come to the bedside in the emergency department to do this procedure. Arthrocentesis is a procedure you can do well and feel confident about your technique.

Take a moment to review our last blog post on knee pain before reading this post and watching the accompanying video. (http://bit.ly/1Q7dG4h.) As always, review the anatomy; it plays a key part in successful bedside technique. Ultrasound-guided arthrocentesis is always a favored approach.

Although emergency physicians and advanced practitioners can complete this procedure at the bedside, we suggest contacting the surgeon involved for post-op patients before starting arthrocentesis. Most surgeons (if in-house at the time) will want to see a hot post-op knee. The surgeon may want to complete the procedure herself or omit a procedure if she does not feel it is necessary. Surgeons also may have concerns about antibiotics use (or misuse) and follow-up care for their patients.

oLandmarks include the medial edge of the surface of the patella or at the middle or superior aspect. Note: The medial approach is typically the first-line approach, although a lateral approach is also an option.

n Position the patient lying supine and extend the knee as far as possible, keeping in mind that flexing the knee to a 20- to30-degree angle may assist with quadriceps relaxation.

n Cleanse the patient’s skin with antiseptic. Recommendations include clorhexidine or Betadine. Remember, if you use Betadine, you should remove the excess using an alcohol swab prior to injection to prevent Betadine from going into the joint itself. Entrance of Betadine into the joint can cause inflammation and should be avoided.

n Apply a sterile fenestrated drape.

n Use a 27 g needle to create a small wheal of anesthetic to the appropriate area. You may use 1% or 2% lidocaine in combination with sodium bicarbonate, approximately a total of 10-15 mLs. The solution is 1:10 mL of bicarb and lidocaine.

n Hold the patella firmly with your non-dominant hand.

n After a wheal is created, position your dominant hand so that it is parallel to the stretcher. Inject the anesthetic slowly into the skin and along the entire track of the aspiration of the needle. Infiltrate the skin down to the area of the joint capsule. The injection track should be dispensed between the posterior portion of the patella and the intercondylar femoral notch.

n Use your non-dominant hand to milk the effusion from the suprapatellar pouch above the patella. This will force fluid into the joint. This will aid in fluid removal as you aspirate.

n Do not forget to aspirate as the needle is advanced.

n Use a large syringe (20 mL is suggested) because there may be a larger-than-expected effusion present. The knee can hold up to about 50-70 mL of fluid.

n If this is your first time completing the procedure, consider using an ultrasound-guided technique to be certain you have the correct landmarks.

n If your first syringe is filled to its entirety, remove it and place a new empty syringe onto the needle. To do this, hold the needle that is in the joint with a hemostat to maintain the correct position. This also stabilizes the needle so you can remove the syringe.

n Another technique is to use a three-way stopcock applied to the needle to allow you to change the syringes without having to remove the needle.

n The procedure can be almost painless to the patient and you can limit his distress if anesthesia is appropriately used. Tense patients with tense muscles do not allow for solid technique, so be sure to aid in patient comfort. As always, we feel patient comfort is half the battle!

n Sedation is rarely required, but may be prudent in some patients. This is not routine practice.

n Always try to remove as much blood or fluid as possible. Large amounts of pus may clog the needle, and the joint may not be totally drained. If this occurs, inject a small portion of the aspirated fluid into the space from the syringe and attempt minor position changes. Do not forget to push down on the suprapatellar pouch.

n Do not completely withdraw and reinsert the needle. If positioning of the needle tip needs to be altered, advance or retract the needle a few millimeters, rotate the bevel or lessen the force of aspiration or injection.

n Avoid side-to-side movements of the needle. Keep the barrel of the syringe parallel to the stretcher.

n It is easier than you think to confuse your sharps after the procedure is completed. Do not accidently toss your sample into the sharps bin.

n Apply a clean, sterile dressing with an ACE bandage to the knee post arthrocentesis.

Tip of the Week

The string test is a bedside technique to determine if the synovial fluid is inflammatory or noninflammatory fluid. Noninflammatory fluid may result from a meniscal tear. To complete this test, place a generous amount of synovial fluid onto your gloved thumb. Touch the drop with your index finger and slowly separate your fingers. A string will be formed as the fluid is stretched and manipulated. A string of approximately 1-2 cm will be evident in a noninflammatory condition. No appreciable string will be formed in an inflammatory synovial fluid such as rheumatoid arthritis. (Clinical Procedures in Emergency Medicine.)

How often do you come in contact with a patient whose chief complaint is knee pain? How often can you actually to do something about it? Collectively as emergency providers, we do not typically fix these types of injuries in the ED, and at times, it is not even certain if we actually diagnose knee pain properly. The truth of the matter is simply that we can diagnose it correctly, help our patients feel better, and give them some answers.

Frequently, traumatic knee pain can be diagnosed as a contusion, generalized strain, or sprain. Rest, ice, compression, elevation, and NSAIDS are often prescribed. If you are lucky, you may encounter the uncommon patellar tendon dislocation, and obtaining a radiograph for traumatic knee injuries may actually yield positive results. At least you can pop it back into place. (Read our previous blog post and watch our video on patellar dislocation at http://bit.ly/1Nd31E9.) The differential diagnosis for knee pain, however, is endless. Here are a few for you to peruse.

In the end, it seems as if we habitually slap a knee immobilizer or ACE bandage on knees, have the patients follow up with an orthopedic specialist, and hope for the best. Knee pain is such a frequent guest in our emergency department that we need to be prepared for its daily arrival. It is time to put an end to the pass off to orthopedics because the buck stops here and now in your ED. We are going to make you all experts by the end of this series on joint injuries and aspiration.

First, let’s discuss the statistics. Many different providers treat knee injuries, but the National Institutes of Health reported 6.6 million people visited the emergency department in the United States from 1999 to 2008 with the chief complaint of knee pain. This is an average rate of 2.29 knee injuries per 1,000 people. Although 42 percent of the knee injuries were diagnosed as a strain or sprain, contusion and abrasions (27%) followed behind. Knee lacerations and punctures (10%) proved to be a solid offender as well, while arthritis, tibial plateau fractures, and other various knee ailments brought up the rear. (Acad Emerg Med 2012;19[4]:378.)

Further statistics reveal knee pain also accounts for approximately “one third of musculoskeletal problems seen in primary care settings.” (Am Fam Physician 2003;68[5]:907.) That means many of these cases of knee pain are first seen by their primary care provider, then possibly by the emergency department, and finally by the orthopedist. That is three providers and an exorbitant amount of time, resources, and money.

Knee pain can also be a source of significant “disability, restricting the ability to work or perform activities of daily living,” according to that same article. This means we need to really start paying closer attention to these patients.

The rate and pattern of knee injuries can vary by sex and age, so it’s important to know what to be concerned about depending on the chief complaint. Adolescent boys will often present with knee pain related to sports injuries. Those over 65 may present with arthritis. It’s very important to know the subtle differences between osteoarthritis and rheumatoid arthritis, which are two completely different ailments. The key is to understand knee pain. This enables clinicians to “better anticipate caseloads, allocate resources, and determine best practices for diagnosis and treatment of knee injuries in different age groups” in the emergency department, according to the Academic Emergency Medicine article.

This month, we are going to ease into our series on joint aspiration mindfully. Later, we will show you the proper procedure via video. This technique needs to be reserved for the correct patient because you do not want to tap every joint that looks irritated or is painful. Our initial portion of this series will begin by discussing traumatic knee injuries and related procedures.

You definitely need to keep the Ottawa Knee Rules in mind. (JAMA 1996;275[8]:611.) The question is, x-ray or don’t x-ray? These rules describe the criteria for knee trauma patients who may warrant knee imaging. The goal is to apply these rules to make your decision. If no criteria are met, imaging is not indicated.

Answering yes to one of these questions mandates imaging:

n Age 55 or over

n Isolated tenderness of the patella (no other bony tenderness)

n Tenderness at the fibular head

n Unable to flex knee to 90°

n Unable to bear weight both immediately and in the ED (4 steps; limping is OK)

Evidence-Based Practice

n Rules have been prospectively validated on multiple occasions in different populations and in children and adults.

n Numerous studies found sensitivities for the Ottawa knee rules of 98%-100% for clinically significant knee fractures. One study did find a sensitivity of just 86%.

n Specificities for the Ottawa knee rules typically range from 19% to 50%, though the rule is not designed/intended for specific diagnosis.

n When used appropriately, the amount of knee x-rays obtained can be reduced by around 20%-30%.

n The Ottawa knee rules are useful in ruling out fractures (high sensitivity) when negative, but poor for ruling in fractures (many false positives).

The creators of the rules at University of Ottawa offer these tips:

n Tenderness of patella is significant only if an isolated finding.

n Use only for injuries less than seven days old.

n Bearing weight counts even if the patient limps.

Precautions from the creators of the rules:

n Do not use on patients under 18.

n Clinical judgment should prevail if examination is unreliable because of intoxication, an uncooperative patient, distracting painful injuries, and diminished sensation in legs.

n Always provide written instructions.

n Encourage follow-up in five to seven days if pain and ability to walk is not better.

The Ottawa knee rules should be applied to all patients 2 and older with knee pain/tenderness in the setting of trauma.

Why Use It

n Patients without criteria for imaging by the Ottawa knee rules are highly unlikely to have a clinically significant fracture and do not need plain radiographs.

n Application of the Ottawa knee rules can reduce the number of unnecessary radiographs by 20-30 percent, which has proven to be cost-effective for patients without reducing quality of care.

Implementation of the Ottawa knee rules would be associated with meaningful reductions in societal health care costs in the United States and Canada without a reduction in quality of care.

Jim weighs in: Most ED patients expect an x-ray of a painful knee, especially if it was traumatized. Most clinicians can readily tell if an x-ray will be helpful, but meeting patient expectations is an important goal. If you are not going to order an x-ray, make sure the patient understands your reasoning and agrees with your tactics. Don’t fight with the patient about an x-ray. Decision rules and your exam are most important, but no exam takes the place of an x-ray to settle the issues in a borderline case. Finally, remember that a CT scan/MRI sees much more than a plain x-ray, so always keep open the possibility that one of these tests may be necessary if the pain, mechanism, and findings suggest an internal injury, symptoms continue, or x-rays are equivocal.

Stay tuned for next month’s Procedural Pause Blog, when we show you how to tap this knee! Can you tap it? Yes, you can.

This blog teaches procedures, with its case studies and videos intended to help you perfect your technique and strengthen your confidence. This month we explore issues related to procedural patient impact. How will your intervention positively or negatively affect patient outcome? What happens when we decide to step in and complete a procedure?

A risk is always inherent when a provider undertakes a procedure, no matter how insignificant. Carefully, we weigh the pros and cons of the potential procedure with our patients. Will our intervention cause a positive effect or outcome? Our goals are to repair, resolve, or restore whatever may have gone wrong. That means there might be some sort of suffering along the way.

Or does it? There is a potential for any procedure to have a poor outcome. Our interventions are intended to help, not hurt the patient under our care.

Patient Impact: Pain Control

Pain control can make a major difference in every procedure, and is a best practice for our patient. Procedures can be completed more effectively and without distraction when a patient has less pain. And we are less likely to make a mistake, stop early, or prolong the procedure when we can perform without interruption. Pain control may even lead to better cosmetic outcomes because the patient is more relaxed, calm, and cooperative. Technique is only half the battle.

Vaginal Abscess I&D

It isimpossible to maintain perfection 100 percent of the time. Poor patient compliance, financial hitches, unrealistic treatment times and department goals, lack of materials, and lack of follow-up, knowledge, and staff all contribute to poor patient outcomes. Procedural complications are not always simply chalked up to poor technique.

No one is perfect. Every day is a learning experience, and we do what we can with the resources we have. You will succeed by embracing basic concepts, using proper equipment, and not cutting corners. Part of that understanding is to use proper pain control, especially when draining a painful, sensitive vaginal abscess, as seen in this video:

During one incision and drainage of an abscess, the patient experienced horrific and traumatizing pain, and she returned two days later with a larger reaccumulated abscess, which had to be excised and drained for a second time. This was not happy news for the patient or the providers involved. The abscess may have reaccumulated despite our initial interventions. It may have returned, however, because it was not appropriately drained or treated the first time. Perhaps adequate drainage was limited because of pain. And she reported during a follow-up call one month later that she had painful and unsightly scar tissue.

Why did the patient have a poor outcome?

§The patient’s pain was poorly managed during the procedure. It did not allow us to complete the procedure appropriately.

§Our ED does not stock Word drainage catheters, which are best used for treating labial and Bartholin cysts/abscesses.

§The nurse had to leave the room for a trauma, and we continued the procedure without pain medication.

§Local anesthesia was not successfully achieved.

§She had poor positioning during the procedure.

§The patient was very fearful.

§The patient was nauseated and vomited during the procedure, creating concern for aspiration and removing conscious sedation as an option.

§The vaginal abscess was not completely drained because the patient was unable to tolerate additional procedure time secondary to lack of pain control.

§The patient stated on the second visit that she felt abused by this procedure, which caused her significant stress. She stated that the physician never asked her if it was OK to discuss medical history in front of her abusive husband, and she had no chance to talk about more personal issues.

§She felt we poorly explained the technique and rushed through it.

§The provider performing the procedure answered her phone three times.

§The patient spoke Spanish only, and though we used an interpreter, her discharge paperwork was in English.

§The patient did not know how to take her own temperature and did not understand she should return for a fever of 104°F.

§The pain medication and antibiotics made her vomit at home, so she never took the right doses.

§The patient could not afford clindamycin anyway.

How do we fix these issues?

The majority of these issues are easy to resolve. This patient may have had a better outcome if the following issues were addressed:

§You aren’t the boss, so you can’t fix staffing numbers, but don’t start any procedure unless you know you have the right people available to help you. Make the patient wait for an urgent procedure until you all can be ready to start without interruptions. Forget about your length of stay.

§If the procedure is emergent, escalate this concern to the charge nurse or another provider and intervene early. You are in charge of the patient.

§Always discuss a full history and perform a full physical before completing any procedure. This means if you are doing a procedural sedation, consider full cardiac and respiratory assessments. Call respiratory for a patient who might crump from COPD issues or orthopedics for an 86-year-old with afib and a dislocated hip. Maybe that one can be done in the OR.

§Discuss all procedures (to your best ability depending on urgency) with the patient and a witness.

§Have the patient sign and acknowledge the risks and benefits on a consent form. Don’t have her sign just for legal purposes. Have her sign so she understands what is going to happen.

§Use an interpreter. Translate the paperwork into the patient’s language. We suggest Google Translate or another professional application your department allows.

§Discuss pain control methods with the patient, and provide excellent pain management and local anesthesia.

§Insert an IV for difficult procedures, such as labial or vaginal abscesses. Give patients adequate IV pain medication before the procedure and before local anesthetic infiltration.

§Inject slowly and give enough lidocaine the first time to adequately block pain of the procedure. Consider a field block. It’s OK to use more lidocaine (generously through the incised skin edge) once the procedure causes pain.

§PO challenge the patient before she is discharged. Consider an antiemetic.

§Sit down and explain how the next 48 hours should look and feel for the patient.

§Consider social work interventions for uninsured patients.

§Use the right equipment.

§Stockpile some discharge paperwork for common procedures or create a document on your computer that highlights your instructions. EPIC, for example, has information about cellulitis. Add some thoughtful additions and touches of your own, and save those as smart phrases. If you use paper charting, spend 10 minutes at home drafting a strong discharge packet. It will prevent patient bouncebacks and save an unbelievable amount of time.

§Note that your involvement in your patient’s care does not stop at discharge. Make a follow-up call the next day for patients about whom you are particularly concerned. It takes almost no time at all to do, and your patients will be so thankful.

Summary

During a busy shift, it is easy to forget or forgo comfort measures or seize a patient teaching opportunity. Slow down! Pause for a minute to provide patients better pain management during uncomfortable and invasive procedures. Not only will it relax your patients, but their ensured and controlled comfort will make your job easier. It is the rare patient who will not benefit from pre-procedural IV opioid analgesia. Be generous!

Evidence-Based Practice Pearl

The most painful procedures for ED patients are nasogastric intubation, abscess incision and drainage, fracture reduction, and urethral catheterization, according to a study of more than 1,000 patients receiving the top 15 emergency department procedures. (Ann Emerg Med 1999;33[6]:652.) The study also showed that overall use of anesthetics before these procedures was low.

It is often noted that pediatric patients do not receive appropriate analgesia in the emergency department and as outpatients because of inadequate dosing. If you decide to give pain medication to pediatric patients, give them the proper dosage and discuss this with the parents.

Most people will experience dental pain or a dental complication at some point in their lives. Dental pain is an incredibly common complaint by people of all ages, especially those who lack dental insurance and suitable hygiene habits. Sometimes, though, poor dentition or injury is simply a result of bad luck. Patients often present to the ED hoping to find a dentist and an answer to their problems.

Your first thought? “I am not a dentist. What am I going to do?” You’re right to an extent. We are not dentists, and often feel we have little to offer patients for acute issues that require equipment we don’t have and don’t know how to use. We certainly cannot assist with long-term tooth maintenance and treatment of chronic pain. As many of us know, pulling teeth in the ED is not something we do on demand and should not be expected to do.

But we can do some procedures in the ED without a dentist being present or even consulted, and we can link the patient with some dental resources. There are many dental schools that accept patients for a marginal fee to improve their training skills. When it comes to educating your patients, suggest brushing twice a day, changing their toothbrush every six months, and having a dental cleaning at that time, too. In fact, we suggest you give out this information to all of your patients in the general discharge paperwork, even if they are not in your ED for dental pain. Give it to those especially on whom you complete smoking cessation instruction. Why not make it easy for them and their teeth? And while you are at it, ask them to tell their friends, too.

The best part about this particular procedure for dental fracture is that anyone can do it, and it only takes a few minutes. It is so simple that the actual procedure fit into a one-minute video.

Regular strength Coe-Pak periodontal bonding agent, left, includes the base and the catalyst, which are needed for activation of the base agent. A set of two cotton swabs with long plastic or wooden stems are needed for mixing and applying the agent, center. A general swirling motion is used to mix the agents together before application, right.

The Procedure

n Have the patient lie on a stretcher at a 45-degree angle with excellent lighting.

n Have the patient bite down on gauze if areas in the mouth are bleeding.

n Depending on the type of fracture, complete appropriate dental block for pain relief. This is rarely needed, but it may be useful depending on patient’s comfort level and extent of dental injury.

n Consider imaging if you are concerned about aspirated foreign body, facial fractures, or head injury.

n Carefully examine the lips, especially those with lacerations. (The last fractured tooth I encountered ended up embedded in the patient’s upper lip, and it needed to be removed before suture repair.)

n Examine and count all teeth, note them by number and approximation. Look for obvious fractures and then also consider micro-fractures from partially damaged fillings or teeth.

n Note: Does your patient have a tongue ring? These can also cause dental trauma. Suggest to the patient that it be removed.

n Prep the area of injury by having a partner set up dry wall suction and applying cotton gauze to the sides of the injured area. Note: The area must be dry or the periodontal bonding agent will not adhere correctly or safely.

n Obtain bonding agents. There are many popular brands and agents (Coe-Pak, Reso-Pac, etc). We are specifically going to talk about Coe-Pak, which consists of a standard base and a catalyst.

n Most bonding agents require mixing the agents in a 1:1 ratio, but products may have different mixing requirements. Find a product you like working with and try to stick with it.

n Did you know that the majority of bonding agents come with a lined mixing packet card or pad? Place this card on a surface and use it to measure your bonding agents/materials before application. An injection gun is also a hot commodity, so hot that these items may be missing from your dental box. Just know they exist!

n Place 1 cm of catalyst and 1 cm of base on the mixing card or other sterile mixing surface. We suggest opening a laceration tray to assist with this procedure because the hemostats may assist in application and sculpting later around the periapical areas. You can also use the instrument tray to mix your chosen product.

n Use a swirling technique to mix the two agents if you have a small area to repair. A tongue blade may assist with this process. This is necessary to complete the chemical reaction and activation sequence of the agents. It takes about 30 seconds to mix most agents.

n Some agents require a “balling up” type of application where a powder is used. These can be applied with your fingers rather easily. Remember to mix the catalyst and base well regardless of the type of bonding. If you are working with a larger area, combine the base and catalyst in a “balling up” process and then roll it out on the table into a tube-like structure (as thin as a pencil) for application.

n Wait approximately five to 10 seconds before application. (Some products differ.)

n Again please note: You may use either method: balling or direct application. We prefer balling the material before application, but direct application is also effective.

n Retract the side of the mouth away from the injured area.

n The now putty-like composite resin can be applied to the dental fracture itself over the natural surface of the tooth, regardless of depth of injury.

n Shape and sculpt the periodontal bonding agent over the tooth/teeth. Create a flat surface (free of lumps and bumps) over the tooth and around the edges interproximally. Be sure the entire tooth is covered. This will allow for stronger hold and protection of the fractured tooth.

n Consider using a small-nosed hemostat to shape the bonding around the injury. DO NOT use scalpels or needles to shape the mixture.

n Most of the time, your fingers shape the area better than any tool. Use saliva from the patient’s mouth to keep it moist if it begins to dry out.

n Wait approximately 60 seconds after applying, and then have the patient bite down (if able) to form a small indentation over the bonding. Be sure the bonding agent has had at least one minute to rest, or the patient may pull off the covering when the teeth meet the bonding.

n Have the patient follow up with an oral surgeon or dentist within 24 hours.

n Dental pain can be excruciating. We suggest prescribing the adult patient ibuprofen 600-800 mg tablets po q. 6-8 hours prn pain relief. NSAIDs will help treat inflammation and irritation to the gums. If you are feeling generous, Percocet or Vicodin will help the patient get at least one night’s rest. Prescribe narcotic pain medication at your discretion and in relation to the extent of patient injury, history, and presentation.

n Suggest that the patient refrain from chewing food or gum on that side of the mouth. Encourage a soft diet.

n Smoking cessation as needed.

n Avoid brushing over the area with toothbrush, but the other teeth can be cleaned.

Dental fracture now dressed with periodontal dressing/bonding agent. It was later sculpted along the gum line for patient comfort and proper adherence.

The Pause

nDo not remix additional bonding agent with dirty hands/contaminated gloves after working inside the patient’s oral cavity. The bonding set usually can be used repeatedly, and it is completely acceptable to store and use the agents again. Do not throw it away after opening, but be sure to adhere to all expiration dates and product directions.

n What happens if the patient swallows any of the periodontal dressing? Most likely, nothing. Tell your patient that the mixture is nontoxic and safe. In fact, people can swallow parts of their braces or actual teeth without any complications. The parts simply pass through the GI system. Inhaling the dressing, however, can be life-threatening.

n The area of injury needs to be dry before application of bonding agent.

n After mixing the bonding agent, wait 10-20 seconds before application. If you apply the mixture immediately, it will not be very easy to use. If you apply it too late, it will harden and not adhere to the tooth for very long. Do not use the cotton portion of the swab to apply the periodontal dressing. Use the stick portion of the swab for mixing and application.

n Homeopathic treatments using clove oil were popular for many years. Clove oil contains eugenol and can help with toothache or inflamed gingiva. Eugenol can cause nerve damage, and should only be used a few times or for one or two days. Most periodontal bonding agents today do not contain eugenol.

n Use bupivacaine 0.5% for dental blocks because it lasts longer for pain control.

Tip of the Month: Ellis Fractures

Ellis I: These crown fractures extend through the enamel only. These teeth are usually not tender and have no visible color change but have rough edges.

Ellis II: This is any fracture that involves enamel and the dentin layer. Teeth will be tender to the touch or air exposure. You may notice exposed dentin (yellow in color).

Ellis III: These fractures involving the enamel, dentin, and pulp layers, and will be exquisitely tender. You will see an area of pink pulp, redness, or blood toward the center of the tooth.

Reminder: Dental pulp may become infected easily. Pulpitis can occur after a dental fracture while patients are waiting to see a dentist or oral surgeon. Place the patient on antibiotics (typically penicillin VK 500 mg PO 4x/day for 10 days). If the patient is allergic, substitute clindamycin 450 mg PO 3x/day for 10 days. Other accepted antibiotics for potential or known infection include erythromycin, metronidazole, and amoxicillin-clavulanate.

Evidence-Based Practice Pearl

Did you do a good job? What did the dentists have to say? A small retrospective study of 25 ED providers found three ways that providers could approach dental fractures or avulsions. (Ann Emerg Med2009;54[4]:585.) The periodontal pack took about four minutes to complete and was financially more appropriate. The study participants had no measurable or agreeable preference for a particular splinting or bandaging technique, but dentists preferred the use of reinforcement ribbon (96%) and light-cured composite (100%) when given the option. The only problem is that reinforcement ribbon and light-cured composite are difficult to obtain, stock, and use in the ED. It is also very costly and specialized, and those factors and the longer treatment time simply cannot be justified for use in the ED when CaOH bonding agents are just as effective. Although the specialist may prefer it, they may have to apply it.

The Language (NEW!)

Every specialty has some sort of new language with which you need to be familiar and use in documentation or description to your colleagues. If you are feeling adventurous and want to learn the dentistry lingo, here is a list of descriptive terminology used for differentiating tooth surfaces. Read our previous blog for more on tooth numbering and dental blocks. (http://bit.ly/1qrrPfA.) If you do consult the oral surgeon or dental consultant, he will want to know the number of the tooth and the location.

If you want to hear some of the lingo, check out this very old video from the University of Michigan, free for public use and distribution for educational purposes. This classic video, although dated, uses principles we still use today. Watch here: http://bit.ly/1d9fxZ0.

Final Thought

The American Heart Association published guidelines in Circulation about using antibiotics prior to dental procedures. They suggested that only those at greatest risk for bad outcomes from infective endocarditis should receive short-term preventive antibiotics before routine dental procedures. (2012;125[20]:2520.) This, of course, only applied to those who were waiting for a routine visit or procedure.

The literature found no compelling evidence that taking antibiotics prior to routine dental procedures prevents infective endocarditis in patients who are at risk of developing a heart infection because their hearts are already exposed to bacteria from the mouth, which can enter their bloodstream during basic daily activities such as brushing or flossing. Trauma, however, should always be considered as a possible increased risk of infection, and antibiotic use is best decided at time of presentation.

Welcome to our new series, “Guts and Gore.” That title should serve as a warning that some of the videos we will use as teaching tools may be controversial and not for weak stomachs. We hope, however, that part of why you became an emergency provider was to handle sticky situations like the ones we will present. People like us have the ability to ignore blood and copious discharge, and instead focus on saving and improving the lives of our patients. Rarely are you thanked for this ability, and we hope this series on guts and gore will improve your technique, even when the going gets tough.

The Approach

n Proper identification of hematoma requiring drainage

n If unsure, use ultrasound-guided technique to identify fluid collection. Note: Much of the blood is a clot, with some free blood.

n Always have the patient lay supine for any I&D procedure to avoid vagal response.

n Mark the area with a pen. Highlight the area that encompasses the hematoma. This area should be carefully watched for the next 24-48 hours if you are concerned about compartment syndrome.

n Call a procedural pause time out.

nInject the skin over the most prominent area of the hematoma with 2-3 mLs of 1% lidocaine with epinephrine. Inject slowly and carefully.

nUse an 11 or 15 blade scalpel to make a 2-3 cm incision over the top of the hematoma where anesthesia was applied. Some hematomas (depending on size) will need a larger incision. Note: A small puncture is not large enough to drain clots.

nAllow the initial blood to ooze out slowly. Add gentle pressure to assist with the drainage and to expel any clots.

n Use your finger or hemostat to help drain the hematoma by inserting it into the cavity when the drainage begins to slow down.

n Once the hematoma has drained to at least half of its initial size, consider using ¼-inch packing to assist with further drainage. Packing is only used for very large hematomas or those with large incision marks.

n Gently clean the area with saline. Do not aggressively irrigate.

n Apply a dry compression dressing with several pieces of gauze.

nWrap the extremity with an ACE bandage on top of the gauze.

n Give the patient a sling if the hematoma is on the wrist or arm. Provide crutches if the hematoma is on a thigh or lower leg to assist with non-weight bearing.

n Have the patient follow up with her primary care provider or the ED in 24-48 hours for wound recheck and packing removal (if used).

n If the patient is on blood thinners such as Coumadin, Xarelto, or Plavix, check back here next month when we will address how to treat these patients.

New! Tip of the Week

Is this an abscess or a hematoma? This month, we introduce a new Procedural Pause challenge. Think outside the box, and be prepared for red herrings. Misleading and distracting diagnoses present in your emergency department on a daily basis. Our hope is that you can recognize the decoy early and act accordingly. We ask you, is this a hematoma or is it something else?

Is it a hematoma or a contusion? Sometimes the only way to know is to open it up. Photos by Martha Roberts, ACNP, CEN

This patient’s left hip actually turned out to be a common contusion, or nefarious hematoma. The patient’s initial complaint was, “I hit my leg a week ago on the bed,” and noticed that the area became “red and irritated.” The patient said the area “turned colors” and “felt kind of squishy and soft.” She also said she had had abscesses before in her groin and on her leg that were MRSA-positive. Ultrasound revealed fluid under the skin. The pocket, however, was not uniform.

The area palpated felt soft and buoyant. The only way to determine if this patient had an abscess with cellulitis or a simple hematoma was to open and drain it. When we opened the area, it was filled with gross blood and clots. There was no abscess at all. From this experience, we learned that patients can (especially those with diabetes) form skin infections related to old contusions. The hematoma was successfully drained, and the patient was placed on prophylactic antibiotics for Pseudomonas coverage. A drain was placed because of the size of the cavity, and she followed up in 24 hours with her primary care provider.

Evidence-Based Practice Pearl

Hematomas are filled with clots. It is a common misconception to assume that large, raised hematomas are filled with unclotted blood that will deflate as soon as punctured. Quite the contrary. Subcutaneous hematomas often are filled with clots, and take several minutes of coaxing and poking to deflate. The incision needs to be large enough to pass larger clots, or the patient will not have relief. Irrigation of the site is also controversial, as is suction, so you try it and let us know how it works. One may also assume that the hematoma has been drained successfully once it no longer bleeds freely. This is not the case. Compartment syndrome may still be lurking.

Compartment syndrome may cause rhabdomyolysis, renal failure, and generalized muscle ischemia. Perioperative morbidity and mortality are high. Fasciotomies are not always the best way to treat these issues. We suggest initial I&D to avoid compartment syndrome and the potential for fasciotomy. The goal is to identify these issues early, so that the latter does not occur. Fasciotomies have been found to be associated with worse outcomes and higher morbidity and mortality. (World J Surg 2003;27[6]:744.) The lesson: Evacuate the hematoma early.

If you have learned anything as a practicing provider or even as a student, we hope it’s the art of misconception. Be sure to question clinical pictures that just don’t add up. Be wary of quickly assuming a diagnosis to be commonplace. Assertiveness is important, but exercising a prudent approach is paramount. When in doubt, take a second look, and you will be everyone’s champion. Most importantly, you will do what is best for your patient. At the end of the day, we all want to sleep at night.

Today you are the fast-track provider, and you are on the hunt for procedures. You notice a 35-year-old woman signing into triage with a chief complaint of wrist pain.

This patient looks otherwise healthy, is pushing a stroller with her right hand, and is carrying a second child on her left. What’s the emergency? There isn’t one, but it is an emergency to this patient because she cannot push that stroller another day! If she cannot push the stroller, then she cannot get the kids to day care. And, if she cannot get the kids to day care, then she cannot go to work. Ask anyone with children, it is an emergency.

This patient also says she is new in town and did not know where else to go, so she came to your Level I trauma center. Good thing you read this blog because you just made her day.

Chronic, recurrent, nontraumatic wrist pain may throw you for a loop. Words like “rheumatoid” and “fibromyalgia” flash in your mind. Things like “ANA” and “lupus” and “we don’t do that in the ED” also pop into your brain. Red flags such as “fever,” “infection,” and “diabetes” slip from your lips. Stay cool; you can totally fix this chronic wrist pain! Not only can you fix it, you can also feel confident about your diagnosis and treatment plan after reading this article. This month, we are going to touch upon — literally — tenosynovitis of the wrist. This painful chronic wrist pain can be solved with a simple two-touch technique.

Tenosynovitis is somewhat like a permit fish. It is rare, hard to catch, and can put up a good fight. Tenosynovitis is just as reclusive as the permit, and you will never forget it once you see it. De Quervain's tenosynovitis is a chronic but sometimes recurrent problem. The syndrome causes an inflammation of the synovium sheaths that surround the tendons of the extensor pollicis brevis and the abductor pollicis longus muscles of the thumb. The two parallel tendons assist with thumb movement. The cause of this type of tenosynovitis is still not well defined, although one of its nicknames is “mommy thumb.” Overuse and irritation can cause a flareup. Its onset causes significant wrist pain, tenderness, and immobility, so it deserves some attention.

The Approach

n Identification of De Quervain’s tenosynovitis using the Finkelstein test and two-tap technique

n Familiarization of proper steroid medications for injection

n Steroid injection into the wrist

n Orthopedic follow-up

n Possible surgery for recurrent issues

The Procedure

n Place the patient in a supine or sitting position. Avoid complications from vagal response by making your patient comfortable.

n Identify your landmarks. Locate the radial styloid process and the base of the thumb on the affected extremity.

n Have the patient make a fist. Then ask her to complete the Finkelstein test: Place the thumb into the fist, so the fist is holding down the thumb. Stress the tendons by having the patient tip her hand toward the ground. This should elicit exquisite pain.

Next, use your second and third fingers to identify the area of concern by tapping with these fingers lightly on the radial side of the wrist. Start at the base of the thumb and make your way up the wrist. This is known as the Roberts two-tap technique or Roberts sign. (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)

Use a marking pen to note the area of extreme tenderness. You will make your injection wherever the patient has the most pain with palpation using the two-finger tapping technique.

n Premedicate the patient with 600-800 mg ibuprofen PO once. If there is a contraindication, consider using 650-1000 mg acetaminophen PO once.

n Order the appropriate corticosteroid from your pharmacy. You should use a long-acting corticosteroid such as Depo-Medrol or Kenalog (there are several brand names for methylprednisolone acetate). Depo-Medrol is an anti-inflammatory glucocorticoid for intramuscular, intra-articular, and soft tissue injection. It is available in three strengths: 20 mg/mL, 40 mg/mL, and 80 mg/mL. The appropriate dose for your adult patient is 40 mg diluted in 2 mL of 1% lidocaine, making a 3 mL dose.

n The lidocaine increases the volume and acts as an anesthetic.

n Clean the area with an alcohol swab.

n Use a 25-27-inch ½ g needle to inject the steroid lidocaine solution directly around the area affecting the tendon sheath. You will not be injecting the tendon directly!

n Note: You may consider injecting 1 mL more of the steroid lidocaine solution proximally and completing another injection more distally to cover the entire affected area. See video for more details.

Watch a video of Dr. Roberts demonstrating diagnosis and treatment of De Quervain’s tenosynovitis.

Cautions

n A plain radiograph is not useful. Refrain from ordering a radiograph if you are quite certain this is tenosynovitis.

n Always consider gout, septic joint, or underlying autoimmune disorder. De Quervain’s tenosynovitis is still not well understood, and there are theories it may linked to lupus, Lyme disease, and other connective tissue disorders.

n Do not repeat injections in a short period of time. Consider telling the patient to wait six months or more before having the area injected again.

n Stenosis of tendons may be an issue. If you feel resistance during injection, you may be injecting the tendon itself, so retract the needle slightly. You cannot inject directly into a tendon. Your goal is to inject the area around the tendon.

n The patient should have complete pain relief in a minute or two if the appropriate area is injected. More solution may be required if not.

n Consider wrist immobilization using a plain thumb spica splint, resting the area, NSAIDs, and ice for patients who decline steroid injection and prefer a more conservative approach. Physical therapy is also an option.

n Oral steroids are not particularly helpful.

n The original pain will recur when the lidocaine wears off. Warn the patient of the post-injection flare — transiently increased pain that may occur in the first 24 hours. You may consider a few other doses of NSAIDs or acetaminophen.

n Temporary distal sensation loss in the thumb from the lidocaine is not uncommon.

n Complete pain relief should be obtained in two to three days.

Final Thoughts

Jim weighs in: Martha is a real wimp.

Martha weighs in: I had to hold the camera and be injected for this video. What the heck?! Thanks, Dad?

Tip of the Week

De Quervain’s tenosynovitis is most commonly seen in 30- to 50-year-olds and mostly women. It is important to ask patients about their daily activities, job, and even sexual history. Gonococcal infection can cause septic arthritis or tenosynovitis. Beware of injecting or jumping to the diagnosis of De Quervain’s if the patient has a fever. Gonoccocal infections can have an insidious onset and may be confused with De Quervain’s. Pain, redness, and swelling with an associated fever are NOT associated with De Quervain’s tenosynovitis. How can you tell the difference? Look for a painless, nonpruritic rash that consists of small papular, pustular, or vesicular lesions. Splinting is generally not required.

Did your procedure work? Call your patient in 48 hours, and if he is feeling back to normal, you found your permit fish! If your patient is a mother of five and her main job is working as a fishing guide in the keys, then you already know you did the right thing.

Evidence-Based Practice Pearl

Don’t be shy. A steroid injection will help your patient. A collective 2003 study citing the Medline and OVID databases on all published cases of De Quervain’s tenosynovitis found an 83 percent cure rate with injection alone. This rate was exponentially higher than any other therapeutic modality (61% for injection and splint, 14% for splint alone, 0% for rest or nonsteroidal anti-inflammatory drugs). The evidence proves that injection alone is the best treatment for De Quervain’s. (J Am Board Fam Med2003;16[2]:102.)

Abscess incision and drainage should be loved and adored by all emergency providers because another abscess is waiting just behind the curtain. This month we highlight general guidelines for abscess incision and drainage, and show how to treat one in the video below. We will follow up with some additional videos in the months to come focusing on scalp, vaginal, and facial abscesses. And, just when you think you have seen it all, we will reveal a few more surprises.

Axillary abscess from hidradenitis. Photo by Martha Roberts.

The Approach

nIdentification of an abscess appropriate for I&D.

nIf unsure, use ultrasound to identify fluid.

nConsider the use of IV or PO pain medication.

nIncision and drainage (I&D).

nPacking application.

nFollow up with packing removal and/or surgical follow-up.

The Procedure

nConsider premedicating the patient with oral Motrin, Percocet, or Vicodin, or IV medication if local infiltration is not sufficient.

nObtain laceration tray or surgical kit for I&D.

nPut patient in comfortable position.

nPrep using sterile gloves to keep it a clean procedure, though it is not meant to be a sterile one.

nAnesthetize the skin with 1% lidocaine. Inject slowly.

nMake a horizontal incision using an 11 or 15 blade scalpel, utilizing the entire length of the abscess. Do not make just a small stab.

nAllow pus to discharge freely at first, and then assist with gentle expression of the opened cavity.

nOnce the cavity is fully expressed, use forceps to delicately break up any of the capsule inside the abscess.

nDepending on the size of the abscess, rinse with gentle jet lavage: 30-50 mLs of sterile water. Four to five sterile flushes usually do the trick.

nPack the abscess with ¼-inch or ½-inch packing gauze. Soak the gauze in Betadine prior to insertion to allow for pliability.

nCover the abscess with sterile gauze and leave in place for 24-48 hours. Try to use as little tape on the skin as possible to avoid further discomfort.

nIf there is an associated cellulitis, then antibiotics may be required. Antibiotics are usually not indicated. We will cover this in future blogs.

nWhen the patient returns, wash out the cavity gently. You do not have to anesthetize the patient for this procedure; just be kind to this sensitive area.

nBonus: If the capsule floats right out, that’s a good sign! Look for a white coated gel-like discharge in sac formation. If the abscess capsule is obvious in the cavity, attempt to remove it.

nDo not be afraid to complete I&D a second time (in 24-48 hours) if the wound has not appropriately drained. This will require anesthetizing the area again.

Cautions

nDo not make the incision too small because it will not drain correctly. Be sure to make it the full length of the abscess. Bigger is better!

nDo not I&D a complicated abscess of the face, neck, or foot. You may consider getting ENT, plastics, or podiatry involved for these wounds because airway, scarring, and diabetes may not allow for standard and safe healing.

nIf you see one abscess, there may be more. Discuss this with your patient. Consider surgical consult for pilonidal abscesses because they tend to recur. The entire cavity may need to be completely and surgically removed. Marsupialization is only beneficial for Bartholin cysts or abscesses.

Tip of the Week

Treating an abscess in a pregnant or post-partum woman? No big deal! You can do it using good judgment and proper follow-up. Stay tuned for future blogs and video workshops when we address vaginal abscesses during and after pregnancy.

Evidence-Based Practice Pearl

What about the immunocompromised patient? These patients make us a bit weak in the knees know. Leave it to the Canadians to help us piece together the literature. A large meta-analysis and database search by Korownyk and Allen suggests even patients who are immunocompromised do not necessarily need antibiotics. Incision and drainage is the treatment for almost all abscesses.

I&D under local anesthetic is “generally sufficient for abscess management” for patients who have no confounding risk factors, the authors write. They also note that “there is no compelling evidence for routine cultures or empiric treatment with antibiotics.” And as far as cultures go, level II evidence reveals “routine cultures do not change managementor outcome for patients presenting with abscesses.” We hope that clears things up for some of you, including the abscess! (Can Fam Physician 2007;53[10]:1680; http://1.usa.gov/1vzP7rC.)

This month we want to touch gently on treating pilonidal abscesses as we continue on our series on abscess incision and drainage. A pilonidal cyst or abscess is a fluid-filled pocket of dead skin cells, or pus. These pockets occur on the back over the tailbone, coccyx, or natal cleft. Pilonidal cysts often remain cysts and do not get infected. If the abscess is ignored or spreads (forms a fistula), then the practitioner should be concerned with a possible bacteremia or systemic infection. Infected pilonidal cysts are painful and sometimes dangerous.

A pilonidal abscess is lurking beneath the surface just above the natal cleft. It is much deeper than it actually appears when palpated. The scarring present is from prior I&Ds of the abscess. Photos by Martha Roberts.

Patients often present to the emergency department embarrassed and unsure of their diagnosis. They think they are doing something wrong, are unclean, or do not wash themselves well. This is not the case, and it is important to assure them they did not cause their ailment. Patients mainly complain of pain over their spine or above their buttock, redness or swelling over the area, discharge, and if infected, fever, nausea, or possible signs and symptoms of sepsis.

Many theories explain why some people develop pilonidal cysts or abscesses. Occasionally they occur due to ingrown hairs or infected hair follicles. Another theory is that pilonidal cysts appear after trauma to that region of the body. “[Many] soldiers developed pilonidal cysts that required a hospital stay” during World War II, and some physicians thought they formed because of the irritation from riding in bumpy Jeeps. The condition was actually called Jeep disease or Jeep seat. (Int J Res Med Sci 2014;2[2]:575.)

This retrospective study found that pilonidal cysts are most common between ages 20 and 30, and affect men more than women. The study also suggests it is more common in physically active age groups and does not show any preference to sedentary workers.

Note that incision and drainage is only completed on abscesses that do not involve the rectum or anus. If you are suspicious of a larger area of infection or fistula, order a CT of the abdomen and pelvis with IV contrast. Always discuss your patients with a colorectal specialist in-house (if you are lucky) or as an outpatient for close follow-up. Rechecking the wound and removing the packing yourself (or by the specialist) in 24-48 hours is ideal for the patient.

It’s time to stop packing pilonidal cysts. We challenge you to try a new approach if you have not already! Vessel loop drainage is used in place of packing sutures. Vessel loop is a plastic material used to circle around the abscess and keep it open to drain. It is especially useful for abscesses in the axilla, groin, and, of course, with pilonidal cysts. The Chinese have used a similar technique called suture-dragging therapy for more than 40 years. (Case Rep Surg 2014; Article ID 425497:1.)

Vessel loop is a modern-day take on this already successful technique. This technique is best described as taking the suture thread itself and forming a loop around the abscess or channel of the abscess. The track is kept open, and each day the patient moves the threading back and forth in the cavity to help express the leftover pus in the cavity. Occasionally, a wound vac is used over larger abscess cavities to help suck out the pus. This treatment can be used with or without marsupialization where the entire cavity or pocket is cut out and excised. The Chinese admit that the incidence of pilonidal sinus in China is low, but the misdiagnosis rate and recurrence rate are high.

Overall, they found that suture-dragging therapy was less invasive, and could speed up sacrum wound cavity healing. Countless research articles also found that positive and negative pressures accelerate healing by increasing local blood flow and the rate of granulation tissue formation.

This spring, more advanced providers will be graduating from nurse practitioner and physician assistant programs than ever before. With that in mind, we want to take a break from procedures and focus on transitioning to becoming a provider.

If it were easy, everyone would be doing it. Always let the patient be your guide when you work in the emergency department. Don’t get hung up on workplace drama or fear of making a mistake. No one is perfect, and it will take time to find your niche. It is up to you to do a good job and seize the day, each and every day from here on out. We only hope we can help you find success in your practice while having some fun along the way.

— Jim and Martha

By Martha Roberts, ACNP

One of the best days of my life (aside from my wedding and the birth of my daughter) was the day I graduated from my nurse practitioner program at Georgetown University. Soon to follow this incredible accomplishment was the day I passed my acute care board exam and received my license and DEA. At that time, I was pretty sure nothing could top those events in my scholarly journey, aside from maybe a future publication, crucial patient save, or fancy paid guest lecture. Needless to say, I was like a freight train — full speed ahead!

As I finished my five-year journey as a registered nurse, I thought to myself: “I will be a nurse forever.” This was not an end to a career but the start of nursing voyage. Optimism was definitely one of my strongest qualities, but nothing could have ever prepared me for the hardships to follow. No one could have prepared me for what came next. The transition from RN to NP was not at all what I expected.

Fortunately for me (I once thought), the hospital I had worked for as an RN asked me to stay on as a midlevel provider. It was unexpected because I had already accepted a position far, far away! The current nurse practitioner pool in this country is competitive, growing, and constantly changing. There are so many exciting opportunities for new graduates. The midlevel role is becoming more important, as is our presence within all hospital care areas. I wanted to explore a new care area and a new hospital, but it seemed to make sense for my family and me to stay. I didn’t need to learn a new computer system or become familiar with a new place. The team I came from stood behind me 100 percent, and I was ready to make them proud. The proposed transition from RN to NP in my hospital seemed like a fuzzy, warm day in spring: easy, care-free, and budding with adventure. I was right about only one of those three things.

I forgot one oddity, that the age-old phrase from the more experienced nurses in our department was, “We eat our young.” I thought this would never happen to me; I had “fans!” I always felt my hospital would be different because I had friends and people I trusted to support me through my undertakings. I assumed they would be supportive and caring and hopefully a bit forgiving as I made mistakes and triumphs as a newly-minted provider. I envisioned days where we all would work as a team to help patients, and everything would move like clockwork. What was shocking was how unfriendly, unprofessional, and cruel the majority of my nursing colleagues were during my role change.

The day I arrived to the ED in my newly-ironed and embroidered white coat, I received a few heckling comments in a “loving way,” but they had jealous undertones. When I put in orders for the first time, my nursing pals scoffed at me, and said things like, “Are you sure you want that?” or “Don’t you mean x-ray, not CT?” It was beyond stressful. When I made a mistake, my fellow nursing friends relished in my shortcomings and made me feel like a complete amateur. Instead of being helpful, they were hurtful. They were quick to tell my higher-ups that I was a failure, and they rarely said, “Good job.”

It really did not matter what I did or how hard I worked. Each day was more difficult than the last. Instead of learning from my experiences, I questioned every decision and order. I didn’t sleep, I cried to my husband and boss, and thought to myself, “I am never going to be any good.” Peculiarly, this helped me learn, and it motivated me to go above and beyond what was traditionally expected. At times, it was painful and frustrating, but I knew the time would come when my nursing friends would say, “You passed the test; we trust you.” That day has yet to come.

While my “fans” found ways to make me feel like a flop, I used their evil for good. I helped publish a text, worked on various side projects, taught, and tutored while I wrote a monthly column. I made procedural movies and took out my frustration running laps around my alma mater. I spent time volunteering outside of work, helping others anonymously, and donated efforts to those who just appreciated a helping hand. I tried not to focus on criticism and instead to capitalize on accomplishments.

What I realized was the more the other providers, hospitalists, and attending physicians liked me, the more my nursing friends hated and disrespected my title. I would order a pelvic exam or lumbar puncture and ask for nursing assistance. The nurses would say, “You are being too needy” or “Come on, you can do that yourself, can’t you?” It was depressing and disheartening. My future seemed desolate and devoid of growth. Then, one of my most beloved attendings gave me some advice I will never forget. “You were a great nurse, but it’s time you start thinking like a provider and less like a nurse.” When he said this, I frowned because I felt like I was still a nurse! He went on to say, “You will always be a nurse at heart, but you need to embrace the cycle of change. No one will respect your evolution until you do.” Although I was still confused about how I would get my team to accept me, I pondered how I was going to change and evolve. From that point on, I started actually thinking like a provider.

A provider talks to her team and doesn’t just divvy out orders. I noted how nurses responded to certain providers I knew were well liked and avoided the behaviors of those they abhorred. I treated the patient as the number-one priority, and the arguments about care technique faded like ghosts. I paused and listened to my team in hopes they would see my growth and good intentions. I took it upon myself to grow each day by speaking less and listening more. I shook hands with my colleagues instead of forcefully instructing their hands.

What I have learned from my change is to practice free of judgment — judgment of myself, my abilities, and others. There will always be people, providers, patients, and personnel who wish to keep you from reaching your goals. You will be tested each shift. What you must discern is the fact from the fiction. Be the best provider you can be without seeming pompous. Be the fastest provider that you can be without being unsafe. Be the most effective provider you can be without being unforgiving. There will always be ups and downs in the emergency department, no matter your role. The true lesson to be learned is how you deal and react to the positive and negative results. Literally.

Do not make a decision based on emotion. Remember when in doubt, check a TSH. Use your brain and the skill set you have so dearly fostered to help guide you during your time of transition or when you are lost in translation. When your team asks you, “What will you do now?” Your answer should be something, even if you are unsure. There will always be that one person who will never like you and that one patient you can never fix. In turn, there will always be an opportunity to teach and a minute to stop and recalibrate. The true champion is the one who can recognize the difference between the two.

Finally, do not beat yourself up over policies, people, or patients you cannot change. Instead, improve on the things you know you can amend. Hindsight is 20/20. When you judge someone or something, you automatically assume someone else is wrong. Believe in yourself and your final decision.

One of the best days of my life was the day I quit my job at the place I felt safe. As it turned out, I wasn’t safe there at all. As difficult as it may be to make a transition to a place where no one knows your name or your practice style, you can always depend on yourself and your training. You cannot teach kindness or a gut feeling. The dose makes the poison, so keep your daily dose of self-inflicted poison light. Board exams are easy to pass when you are up against a pack of wolves. Take a breath in the stockroom, and remain par for the course. Keep your heart open, and I guarantee you that you will continue to find success.

We are pleased to bring you our first full-length tutorial on abscess drainage. Part 1 of this series focuses on set up and basics for all beginners.

It is important to note that you should practice on injection techniques and how to properly hold instruments before draining your first abscess. No one likes a shaky, unsure hand. We also believe in the “see one, do one, teach one” mentality. Be sure to check out the stockroom at your facility so you, too, can become familiar with all of the equipment used to drain an abscess properly.

Stay tuned for next month’s blog when we get down to draining the real thing. We have every abscess from the neck down!

Picture this: It’s Dec. 31 at 11:59 p.m. You’re spending your designated holiday working the overnight. You’re eating some leftover fruitcake in the nurse’s lounge, and you see the following complaint sign into triage: “Drunk/face pain.”

This could mean just about anything when ethanol is on board. You lift your head just slightly over the computer screen and see a young gentleman staggering in the hall. His chart is labeled “SLC” for “streamline care.” Everyone knows that intoxicated patients are never appropriate for your streamline care area, but you decide to take a chance, and hope this guy has something easy to fix.

Simple eyebrow laceration. Note misalignment of eyebrow.

Credit: Martha Roberts

This is something youcanfix. There is no need to consult plastics or transfer this patient to another facility. You are actually pretty lucky because the laceration goes right though the eyebrow and spares the orbit and globe space. This patient also denies any other injury, and the bleeding is controlled. He is awake, alert, and — surprisingly — not rude! He is obviously intoxicated but behaving appropriately. It is important to take caution with inebriated patients because ethanol can mask pain and other complications. These patients need a full evaluation and often repeat questioning. You can be the judge on how far you want to work up this type of injury, but we can make a few suggestions.

The Approach

§Local infiltration analgesia 1% lidocaine with epinephrine is best. There is no need for 2% lidocaine, and it is OK to use with epinephrine if you find bleeding is complicating things.

Local infiltration of lidocaine to injured area prepping for suture repair. Inject through the laceration edge, not the skin.

Credit:Martha Roberts

The Procedure

§Proper questioning and full examination. Localize the acute injury and survey other possible injuries.

§Order appropriate imaging based on exam and history.

§Clean the area around the eyebrow laceration with 10% povidone-iodine or chlorhexidine gluconate. Do not allow this to enter the wound itself. (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)

§Anesthetize the area. A local infiltration of 1%, not 2% lidocaine, is sufficient.

§Allow just a few minutes for anesthesia to take effect, and test the area with a clean new needle to see if the patient experiences any pain.

§Inspect the area with magnification to check for any foreign body. Gently rinsing the interior of the wound is required. Copious irrigation may cause more damage to the delicate facial tissues.

§Use as little debridement as possible, but whatever is necessary.

§Use a 6.0 or 5.0 prolene suture to close the wound. Note: Subcutaneous sutures may be used. Prolene is the least secure when dealing with knot security, but it has the best tensile strength. It also has the least tissue reactivity (compared with nylon and silk) and handles well. (Roberts JR, Hedges JR, 2014.)

§Prolene is the best choice for eyebrow laceration because it can be easily identified during suture removal from the eyebrow because of its bluish hue.

§Your best choice here is simple interrupted. The first suture re-approximates the edges of the eyebrow.Deep lacerations may be best closed by also using subcutaneous sutures. The case above is borderline.

§You may consider using skin glue if the laceration is superficial. The case above is too large and not appropriate for skin glue.

§You can reinforce skin glue or sutures with Steri-Strips.

§Have the patient keep the area uncovered!

§Topical bacitracin has not been proven effective. It often keeps the area too moist and prevents proper wound healing, causing scarring.

§Does the patient also have a scalp laceration? Note that these can bleed freely without a pressure dressing and should be repaired rapidly. Using lidocaine with epinephrine decreases bleeding during repair of scalp and facial lacerations.

§Keep good form when handling the forceps using the thenar grip technique and lift the skin gently, allowing for the best cosmetic results. The less insult to the skin after the initial trauma, the better.

§Do not tie the sutures too tightly. Instead, loosely apply the first throw and then reinforce the second, third, and fourth throws.

§DO NOT grab too much tissue while suturing, crowd your sutures, space out your sutures, or stick the same area more than once.

§Definitely consider ophthalmology or plastic surgery consult for this repair if the wound extends past the browline onto the eyelid. Most ED clinicians can repair these injuries, but a canaliculus injury should also be considered and discussed with appropriate consults if possible. (Roberts JR, Hedges JR, 2014.)

Evidence-Based Pearl: Closing Old Facial Wounds

A patient shows up in your emergency department with a facial and an eyebrow laceration. The original injury occurred “sometime yesterday.” Can you repair both or none? Do these wounds need antibiotics? The answer is: You can repair both, and you do not needantibiotics. How do we get away with this type of repair safely? For simple lacerations, anesthetize the area and simply trim away the edges of the old wound opening. Use a no. 15 blade, a 1 mm-deep incision with an undermining technique. (Roberts JR, Hedges JR, 2014.) As noted above, 5.0 and 6.0 (not 7.0) prolene is appropriate for the eyebrow, 6.0 nylon for the face.

Most lacerations heal without complications regardless of management. “Mismanagement may result in wound infections, prolonged convalescence, unsightly and dysfunctional scars, and, rarely, mortality,” according to a study in the Annals of Emergency Medicine. (1999;34[3]:356.) Simply put, avoid infection and anything that may cause an unpleasant scar. Going Green means keeping your body green.

Finally, if the patient is a smoker and is expressing cosmetic concerns, here is your chance to suggest smoking cessation. Cigarette smoking causes delayed wound healing. Nicotine is a vasoconstrictor that “reduces nutritional blood flow to the skin, resulting in tissue ischemia and impaired healing of injured tissue. Nicotine also increases platelet adhesiveness, “raising the risk of thrombotic microvascular occlusion and tissue ischemia.” (Am J Med 1992;93[1A]:22S.) These data have been around for decades.

Proliferation of “red blood cells, fibroblasts, and macrophages is reduced by nicotine,” the same study said. Carbon monoxide, which is also in cigarettes, interferes with oxygen transport. Statistically, smokers heal more slowly from all injuries and illnesses. The study also revealed that nonsmokers have a higher incidence of unsatisfactory healing after facelift surgery. Remind your patients who smoke and demand immediate resolution of their issues about the dangers of smoking in general.

We feel it is extremely important to highlight some golden rules and additional pearls after our recent lumbar puncture series. (Read the first two articles about positioning and technique at http://bit.ly/1zRSOdC and http://bit.ly/1wY8MiJ.) These tips will help you ensure the best outcome for your patients.

Be Prepared

§Be aware that patients will be anxious.

□Spend dedicated time reviewing the procedure and informed consent.

□Make sure that they feel only the lidocaine injection.

□Most patients will do better with Versed as long as there are no contraindications.

§Be prepared for patients to vagal! It happens.

□Keep the patient on the monitor at all times.

§Bring an extra kit, sterile gloves, 1% lidocaine, and a partner to help you.

□PA student, anyone?

§Walk the sample to the lab.

□Do not send it in the tube system, and take it to the lab immediately.

The Evidence-Based Practice: Perfect positioning is a must before, during, and after an LP. The question remains, is LP positioning post-procedure just as important? Rumor has it that patients should lay supine for at least one hour after you have obtained your samples, but have you ever thought of mentioning to your patient to try bed rest for 24 hours? What is the consensus? An older controlled study found that it doesn’t really matter what you do. (The Lancet 1981;2[8256]:1133.)

The study compared 100 neurological patients post-LP for onset of headache. The same needle size was used for each patient, and all patients were questioned about post-LP headache. Fifty of the 100 patients were kept ambulant, and the other 50 were given 24 hours of bed rest. The incidence of headache between the two groups was not significantly different. Another study proved post-LP headache was not associated with ambulation or bed rest up to six days post-procedure. (Neurology 1992;42[10]:1884.) The study also noted that CSF opening pressure, cells, and protein, patient's position during LP, the duration of recumbence following LP, and the amount of CSF removed at the time of LP did not influence the occurrence of headache.

Martha weighs in: Let them rest if they are going to go home, and give them a work note. If they want to get up and go to the bathroom instead of using the bedpan, go for it, unless, of course, they are altered!

Jim weighs in: Treatment of a post-LP headache can be managed (debatably) with IV fluids, oral hydration, rest, analgesia, and other treatment options, such as a blood patch.

Vital sign check. Always check in and notice subtle changes in vital signs. A fluid bolus for dehydrated or meningitis patients may help keep things normalized.

Credit: Martha Roberts

Know Your Complications

§Headache: Who gets it?

□Thin people with less body fat.

□Pregnant women.

□The young (18-30).

□The very old (over 80).

§Blood patch:

□You may need to seal off the entry site. Call anesthesia.

§Questionable samples:

□Were you looking for xanthochromia and didn’t find any? If so, and you are still concerned for an SAH, get a CT angiogram and a neurology consult STAT!

□Did you obtain cultures, and they are pending? Do you have a high suspicion for bacterial meningitis? Treat and admit.

The Evidence-Based Practice: We already mentioned that post-LP headache might develop or worsen. The International Headache Society defines post-LP headaches as bilateral ones that “develop within seven days after a lumbar puncture and that disappear within 14 days. The headache worsens within 15 minutes of resuming an upright position and disappears or improves within 30 minutes of resuming the recumbent position.” (Cephalalgia 2004;24[Suppl 1]:9.) Patients need to know that they should come back to the ED if they still have a headache after 48 hours or develop any new symptoms such as vertigo, nausea, vomiting, vision changes, or confusion.

This is all great information to know, but what is the treatment for a post-LP headache? Your plan might be a bit different if your patient is being admitted. We know choice of analgesia could depend on your diagnosis. A blood patch may be an option for some patients. This is a procedure completed by anesthesia. It is created by adding the patient’s blood to the epidural space where the puncture was done. This blood clot stops the CSF from leaking and can help resolve symptoms. About 30 mL of blood from the patient’s vein is inserted into or around the space post-procedure. The patient then lays supine for one to two hours in-house and may be admitted. Decisions on this are made by anesthesia.

A blood patch can be done within the first 24 hours and is successful about 80-90 percent of the time. (Brit J Anesth 2003;91[5]:718.) Lastly, do you have a really convincing story but no xanthochromia? If you feel that the CT and the tap are wrong and your patient may still indeed have something bad, call neurology. You may have a mildly bloody tap (i.e., the cell count in tube #1 is 89 and in tube #4 is 29 with no xanthochromia). You may consider doing a CT angiogram to rule out aneurysm rupture or missed subarachnoid hemorrhage.

Martha weighs in: Why not just use a 20-22 g needle for your tap? Avoid numerous attempts and always keep the bevel up. This will allow you to separate the fibers within the space rather than rip them apart.

Jim weighs in: Interpreting the results of an LP can be difficult, and it’s always essential to be cautious of any blood in the sample, which can be a traumatic tap or bleeding from pathology.

Bonus Videos

Click here to watch this video of Dr. Susan Friedmann of Inova Fairfax Hospital ED in Falls Church, VA, creating a proper sterile clean field for an LP and draping the patient. It also shows proper lidocaine injection technique.

Click here to watch a video of Dr. Friedmann using 20 g needle during an LP for proper CSF removal.

The Evidence-Based Practice: You tried and your attending tried, but there is no CSF to send off for testing. Call your radiologist friend and do the LP under fluoro. The evidence shows that fluoroscopy-guided lumbar puncture with suspected SAH and negative CT findings “should reduce the frequency of false-positive diagnoses of acute SAH as well as the number of unnecessary angiograms for patients with suspected SAH but no underlying intracranial vascular malformation.” (AJNRAm J Neuroradiol 2001;22[3]:571.)

Martha weighs in: Make friends with your radiologist and walk your patient over. If you can, stay for the procedure. I know you are all busy, but watch one of these at least once!

Jim weighs in: Some LPs just can’t be accomplished in the ED. Limit your attempts to three.

Do you have golden rules about lumbar puncture to share? Please leave them in the comments section below.

This month we are back (no pun intended) with the second part of our mini-series focused on perfect patient positioning and lumbar puncture (LP). Part one can be found at http://bit.ly/ProceduralPause.

Now that you have the proper skills to position your patient for an LP, the procedure should be pretty simple, right? The answer is yes! We want you all to be experts. We know that you can and will master an LP after reading these short and sweet LP guidelines and clinical pearls.

You have already decided you will complete an LP. A few common reasons an LP may be indicated in the emergency department include:

n Headache with a fever (rule out meningitis or a central nervous system infection)

n Sudden “thunderclap” headache (rule out subarachnoid hemorrhage)

n Altered mental status

n Idiopathic intracranial hypertension

Always remember to consider the risks and benefits for any procedure and refer to the contraindications. Obtain informed consent before you perfectly position your patient and get sterile! Make sure you review the risks and benefits with each patient.

n Give appropriate dosage of IV sedation such as midazolam (0.1-2.5 mg for patients 18-60) or fentanyl (0.5-1.5 mcg/kg for adults 18-20), if indicated. Sedation is recommended for all procedures because of test anxiety.

n Open your LP kit and loosen the tops of all four of your sample tubes, but do not leave them open to air. Ask a partner/RN/tech to drop a sterile 10 mL syringe into the sterile field. LP kits usually only come with 3-5 mL syringes and not nearly enough lidocaine for appropriate anesthesia.

n Draw up your lidocaine into a syringe, and have it ready on the sidelines.

n Clean the patient’s back with antiseptic. Use extra if necessary. Clean using a circular motion from center extending outward in a large circle.

n Slide a sterile drape between the patient’s hip and the stretcher. This is the point at which many people tend to break the sterile field. If you do, simply put on a new set of sterile gloves.

n Use an additional drape with a hole over the site where you plan to insert the spinal needle.

n Warn patients of the needle stick.

nInfiltrate the skin over your landmark (between L4-L5 spinous process) with lidocaine injection. Start with a wheel under the skin using a 1.5-inch, 25-gauge needle and advance to subcutaneous tissue. A total of 5-10 mLs can be inserted. This is usually a painless procedure if you use enough lidocaine. It’s painful if you don’t.

nWait one to two minutes. A common error is to fail to measure the opening pressure. Set up a stopcock and a manometer for opening pressure. (Note: Remember, this can only be obtained in lateral decubitus position, NOT sitting.) Ensure that the valve is working.

n Hold the selected spinal needle (3.5-inch, 20-gauge needle preferred) between your thumb and index finger of your non-dominant hand and insert perpendicularly into skin over the landmark by pressing the hub of the needle with your dominant thumb. (Pediatric LP to be covered later.)

n Slowly advance the needle below the L4 spinous process. Once you have infiltrated the subcutaneous tissue, aim the needle toward the umbilicus.

n Note: When you pass through the intra- and supra-spinal ligaments, you may feel a slight pop. If you feel bone (articular process), slowly remove the needle and ensure you are entering the midline of the spine. Re-angle your needle slightly to the left or right.

n Your goal is to reach the subarachnoid space.

n Attach the manometer, and obtain a pressure. The stopcock allows you to obtain the pressure and obtain CSF. Normal pressure is 7-20 cm/H20.

n Remove and replace the stylet at various stations (every few millimeters of advancements), entering the spinal column to check for CSF.

n Place bandage over infiltrated area and have patient lie supine for 30-60 minutes before sitting, standing, or walking to help avoid post-procedure spinal headache.

Find your landmarks by creating an imaginary line using this photo as a reference.

Martha Roberts

Cautions

n Do not do this procedure without sedation, especially on those with altered mental status.

n Be generous with lidocaine administration.

n Be sure your needle is in midline and angled properly.

n Have an assistant help hold your manometer.

n Frequently check for spinal fluid once you are in the area by removing the stylet.

n Do not move the needle tip once you obtain CSF.

Tip of the Week

We all love to tape the lidocaine bottle to the stretcher post so we can draw up our own lidocaine without an assistant. We urge you, however, to grab a partner for this procedure. Your partner can provide an extra set of hands and patient comfort. It is vital to ensure that a nurse is close by to administer needed medications prior to the procedure. A difficult or altered patient is just too tricky to handle one-on-one, no matter how good you may be at LPs!

Evidence-Based Practice Pearl

A study in the New England Journal of Medicine discusses the use of head CTs in suspected meningitis patients. Clinical characteristics were identified in patients prior to receiving head CTs. If certain neurological characteristics were not present, the patients were unlikely to have an abnormal CT scan. The study concluded by stating that patients without specific neurologic abnormality characteristics at baseline (based on the Modified National Institutes of Health Stroke Scale) had a negative predictive value of 97%. The head CT was normal for 93 of 96 patients. Was it really necessary in absence of clinical abnormalities? Maybe not, but no one really wants to be that three percent. (N Engl J Med 2001;345[24]:1727.)

Stay tuned for our third and final edition of this mini-series next month, “How to Handle Lumbar Puncture Results.”

Do you have any tips that help make LPs easier? Share them in the comments section below.

We love breaking down and simplifying complicated procedures so you can perform them easily and efficiently. The next few blog posts will focus on strengthening your practice.

We want to give appropriate and safe care. We also want to consider patient satisfaction, dignity, and comfort when we complete any procedure. This month, we are focusing on procedures that require perfect patient positioning. Half the battle of any procedure is setting up your stage to perform, no matter how complex or simple the task at hand may be. Successful procedures are all about positioning and patient comfort. The better the positioning, the better the procedure and overall outcome.

Consider the correct setup before you start a lumbar puncture. Is the patient young, thin, and tall with a fever? Or older and morbidly obese with altered mental status? Does he have some underlying condition like COPD or heart failure, which makes lying flat or even on his side almost impossible? Does the patient have a history of back surgery or infection that complicates the situation even more? Is he allergic to analgesics or lidocaine — or emergency providers? Next month’s blog will break down the actual steps you need to complete a successful LP, but this month just consider the setup.

PositioningSuppliesn Grab an LP kit. Get an extra kit and leave it outside the room (to avoid contamination if not used). You don’t want to leave the room once the procedure has started, so also grab an assistant.n Additional bottle of Betadine or other cleansing solution.n Extra 1% lidocaine (Kits usually only come with 3 mL vials, and you need 10 mLs.)n Extra needle: one or two 3.5-inch, 20-gauge needle(s) for adultsn Pillow (Three blankets will also do.)n Extra set of sterile gloves in your size.n Versed or Fentanyl for sedation if appropriate.

Lateral Recumbent Position or Side-Lying Position Positioning for Lumbar Puncturen The patient should be fully undressed for this procedure and in a room on a flat and stable surface.n Obtain consent. Review pros, cons, and risks vs. benefits prior to procedure with patient or medical beneficiary. Still complete consent with “emergent procedure” if indicated.n Explain the procedure to the patient. Lessen fears by stating the numbing needle is small and should not be incredibly painful. They may feel pressure once the numbing medication is inserted, but should not feel pain.n Note to the concerned patient, that removal of CSF from an LP is commonly regenerated within the subarachnoid space within one hour.n State that the actual procedure itself is not long (5-10 minutes) and that the prepping usually takes longer. Make sure to mention you care about his comfort and safety.n Assist the patient into a lateral recumbent position, with his back facing you.n Place a pillow or a few blankets under his head and between his knees. The legs should be parallel.n Let the patient get comfortable and settle in this position.n Find your landmarks.

Finding Landmarksn Find the highest points of the iliac crests visually and by palpation. Draw an imaginary line between them to the anatomic midline. This is the fourth lumbar vertebral body. L3-L5 can also be felt by palpation in a thin adult or pediatric patient.n The correct level of entry of the spinal needle is “most easily determined with the patient sitting upright or standing,” and the spinal needle can be “safely inserted into the subarachnoid space at the L3/4 or L4/5 interspace, since this is well below the termination of the spinal cord.” (Lumbar puncture: Technique, indications, contraindications, and complications in adults. UptoDate; Sept. 18, 2013.)

Additional Pearlsn State one of these phrases to the patient: “Curl your back like a cat,” or “Get into the fetal position.”n They should have neck, back, hips and legs in flexion.n Set up your LP kit with the patient’s back facing you. Place it within close reach. There is no reason to set up the kit with the patient watching or before you have found your landmarks and feel confident you can complete the procedure.n An assistant can help with positioning.

Sitting Upright Position for Lumbar PunctureThe steps for prepping this position are virtually the same as the lateral recumbent position. The difference is that this patient is sitting upright and hunched slightly forward. Have the patient place his head on his crossed arms over the mayo stand while he sits on the side of the stretcher. You must determine your landmarks before starting and prepping. Consider the following, however, before using an upright position.n You cannot obtain the opening pressure in the upright position if you are concerned about increased ICP.n Patients may become more nervous and uncooperative in this position.n The upright position is more effective for obese patients.n You need an assistant for this position and a stable patient.n It is practical to give an anxious patient an appropriate dose of a benzodiazepine (IV or PO), but use caution in the upright position.

Cautionsn The opening “pop” you feel is the needle penetrating the surrounding ligaments.n Never complete an LP with infection near the puncture site (i.e. cellulitis, open sore, wound, etc.)n Completing an LP in a patient with a space-occupying lesion (i.e., abscess, tumor) causes risk for brain herniation.n Relative contraindications include coagulopathy, increased ICP caused by space-occupying lesion, and severe thrombocytopenia.n Thirty-one percent of adult patients have termination of the spinal cord at L2; the rest, above.n Needle choice and bore size can influence the risk of a post-LP headache.n Become familiar with both types of spinal needles: standard point (triangle shape puncture (Quincke) vs. pencil point (Whitacre or Sprotte). The Whitacre needle has been associated with decreased risk of post-LP headache. (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)n Note: Pediatric LP considerations will be covered in a future blog post.

The 22-gauge, 3.5-inch Quincke spinal needle is the most common one used by many practitioners for image-guided injection (22-gauge with black hub, 25-gauge with light blue hub; tip of 22-gauge needle is shown at various angles of rotation). The Quincke needle has a sharp bevel that advances easily through tissue planes. Most manufacturers produce a needle with a central stylette that has a small notch in the hub. The notch lies on the same side as the needle’s bevel face, and can be used to determine the direction of the bevel as the needle is advanced.Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medicine; Lippincott Williams & Wilkins, 2011.

Procedural Pearl: What’s with the headache? Patients with idiopathic intracranial hypertension (IIH) will often have normal neuroimaging studies. The increased ICP may be ongoing and cause headaches worse with position changes, coughing, visual loss, chronic pain, or cranial nerve palsies. The only way to diagnose and relieve IIH is to complete an LP. The opening pressure, therefore, should be obtained with a manometer on every patient with a headache, altered mental status, or chronic headache receiving an LP in the ED. Normal pressures are between 7-20 cm H20. Any elevation should be alarming and noted to be abnormal. The concern for IIH would be if the opening pressure was 25-45 cm H20. (Roberts & Hedges, 2014).

Note on Local Anesthesia: A generous amount of 1% plain lidocaine can render the procedure almost totally painless. After a skin wheal, advance the long 25-gauge needle in the same direction and depth that the spinal needle will follow. Anesthetize deeply and widely using 5-6 mL of lidocaine. We’ll get into more of this next month.

Tip of the Week: This month’s tip of the week comes from Dr. Amie Woods at Inova Fairfax Emergency Department. Dr. Woods suggests using a bit more lidocaine to numb the area effectively before completing the actual LP. It is more comfortable for the patient and allows you to complete the LP with virtually no discomfort. She suggests drawing up an additional amount of 1% lidocaine in a 10 mL syringe, maintaining sterility.

Go Green: We know it’s not appropriate to save pieces of a kit used for a lumbar puncture, especially if the kit was taken into a room and used for a patient on isolation. This is why we suggest leaving the second kit just outside the door within reach, and having an assistant hand it to you if you need to start over.

As we approach the end of summer, we pay tribute to a special nerve block. This particular block is crucial for treating lower lip lacerations that may be related to slips and falls at the pool or skateboarding. We are going to ask you to go mental, as in blocking the mental nerve of the face.

The mental nerve is an extension of the inferior alveolar nerve, which branches primarily off the trigeminal nerve. It is a sensory nerve that provides sensation to the lower chin and lip. It does not supply sensory innervation to the lower teeth, although some patients report mild anesthesia to their teeth. Three branches come out of the foramen; two go to the skin of the chin and one to the lower lip.

Mental artery and nerve positions.

Head and neck regional anesthesia is useful for a variety of reasons. A single but precise nerve injection allows the practitioner to spread a large area of anesthesia to specific parts of the face for suture repair. The injured area may be delicate and sensitive, especially complicated injuries to the lip. Many facial nerve blocks are accomplished by using landmarks that are easily identifiable. Intraoral needle entry may help avoid additional trauma to the outside skin surface. A nerve block allows suture repair without distortion or swelling that can occur with local injection. Finally, the procedure itself commands straightforward knowledge of the anatomy and requires only a few simple supplies.

·Place side rails up on stretcher so the patient can hold onto them as you inject. Patients have a tendency to grab or swat away your hand in response to the initial injection.

·Identify your landmarks. Have your patient look forward and draw an imaginary line from the pupil down to the lower jaw. The mental nerve is midline to the pupil.

·Place your pointer finger in the mouth along the gum in line with the pupil. Locate the foramen of the left or right side of the mental nerve. To do this, palpate 1 cm below the base of the second premolar (tooth #20 or #29, fifth tooth from the midline)between the lip and teeth. The foramen may be very difficult to palpate.

·Generously squirt or squeeze topical anesthetic of your choice onto cotton-tipped applicators and place them on your landmark(s). The applicators are placed on the mucosa at the base of the space between the teeth and lip. Leave in the patient’s mouth for three to five minutes.

·Draw up 3-5 mLs of bupivacaine into a 3 or 5 mL syringe. Obtain 25 or 27 gauge 1½-inch needle for injection.

·Grab the lower lip with thumb and pointer finger with non-dominant hand and pull it gently outward, as if you are holding a large mouth bass.

·Remember that the full length of the needle should never be fully inserted when using an intraoral approach for any nerve block.

·Do not change the direction of the needle while it is inserted during injection. Pull back and change position.

·Aspiration before injection is key.

·Minimize pain by injecting anesthesia slowly.

·Use a topical numbing agent whenever possible to minimize pain prior to injection. This block is nearly painless with proper topical anesthesia and a slow injection.

·Always take into consideration that any injection to the face causes anxiety for the patient. Be sure to explain to the patient your procedure before injecting so that he remains still and comfortable while you work.

Tip of the Week

Next time you head to the dentist, why not ask for some one-on-one teaching? These guys are experts when it comes to facial anatomy and nerves. Although there is some mild anesthesia provided to the first and second premolars by blocking the mental nerve, you should note this is NOT the primary procedure for actual dental work or dental blocks. Please see our blog from March 2013 for more information about the inferior alveolar nerve block. (https://bit.ly/Xff403.)

(NEW!) Evidence-Based Practice Pearl

A randomized, controlled, double-blind study in the Journal of Endodontics by Whitworth et al. found the speed of injection reduces the pain of injection while performing a mental nerve block. About 50 percent of the tested patient population reported anesthesia to their first molars, bicuspids, and lateral incisors. For all your statistical nerds out there, the P value was <0.001.

It’s summertime, and people are spending a lot of time outside in their yards, at the pool, traveling, hiking, and getting their fingers caught in things. That makes it the perfect time for a tribute to finger lacerations, specifically those with nail bed disruption and avulsion.

You will need to do a bit of handy work yourself if you work in an urgent care center that does not have a hand specialist on call 24/7. Finger lacerations can be complicated, but you simply need to keep in mind the basic principles about repair of soft tissue injuries. It is also important to identify tuft fractures and tendon disruption.

Hand injuries are incredibly common and amazingly painful. Sometimes a hand injury can keep someone out of work for several weeks, especially if the patient works in an industrial environment or in areas where he may be exposed to chemicals. Close follow-up is indicated and often times antibiotics are warranted to avoid complications because our hands and fingers are so susceptible to infection. Pediatric hand injuries are even more frustrating for parents and kids alike. We encourage you to read our previous blogs about soft tissue injuries and brush up on the basics. (http://bit.ly/ProceduralPause.)

Finger laceration with nail bed disruption. The proximal base of the nail is totally avulsed (left) and overlying the eponychial fold. The avulsed nail should be replaced anatomically but left attached to the intact nail bed. Credit: Martha Roberts

You will need to use a ring cutter if ring removal is not possible. Substantial swelling will occur with the injury itself and with digital block. Order appropriate radiographs of the finger, not just the hand, after examining the patient. Appropriate views include the AP, lateral, and oblique. Lateral views of the finger allow the provider to see subtle dislocations and avulsion fractures. A tuft is the most common fracture. Have the patient on a stretcher in a comfortable position. The patient most likely to syncopize during treatment is a young man in his 20s and 30s (proven by our own research). Digital blocks are routinely necessary for this type of injury. Note: Skin repairs are done after the dislocation is reduced. Clean the area with saline or tap water. A recent multicenter comparison of tap water versus sterile saline for wound irrigation in more than 600 patients found that both irrigants had equivalent rates of wound infection. (Acad Emerg Med 2007;14[5]:404.)

Use a betadine solution or other antiseptic to clean the area. Do not soak for long periods of time. Five minutes is sufficient.

Nail Removal and Replacement Remove the nail from the nail bed completely if the nail bed requires sutures. Place small scissors between the nail and nail bed and spread/advance them, being careful not to cut the nail bed. Save the nail; it will be replaced after the repair. You may use a piece of the suture packet cut in the shape of the nail instead if the nail is not reusable or missing. Place a hole for drainage in the middle of the removed nail. Leave the nail in place if it is adhered to the eponychial space. But you must repair it if the nail can be lifted off and a laceration is underneath. Remove the distal pieces if the nail is shattered into pieces, but keep as much of the original nail left intact to the eponychial space as possible. Extensively clean the area under the nail, removing any debris or foreign bodies. Do not injure the intact nail bed. Use a 6.0 or 7.0 absorbable suture for nail bed laceration repair. Remember that the new nail will grow over the repaired nail bed, and it should be flat and well aligned to prevent permanent nail deformities. Complete lateral nail lacerations first. (Roberts JR, Hedges JR, Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.) A finger tourniquet should be routine, but don’t forget to remove them. Replace the nail in its original position once lacerations are repaired. Use a 4.0 removable suture to secure the nail back into the eponychium using four to six sutures, depending on the size of nail. The nail is replaced not only to act as a protective agent during the healing process, but also to facilitate growth of new nail by maintaining the fold. This helps prevent nail splitting or deformities. Note: Nail growth occurs at a rate of 0.1 mm/day, and it takes about six months for full regeneration of the nail. (Roberts & Hedges, 2014.)

Wound Care and Splinting Apply a bulky dressing with a finger splint for simple DIP injuries. Splints will be kept on for two to three weeks or longer depending on fracture or severity. Larger areas of injury may need full volar or dorsal splints. (See below.)

Discharge Considerations and Other Essentials Tuft fractures are open fractures, but routine antibiotic use is controversial, and infection rates are actually low. Suggested antibiotics to consider: First-generation cephalosporin such as cephalexin 500 mg qid for five to seven days or antistaphylococcal penicillin such as dicloxacillin 500 mg PO qid five to seven days. PCN allergy? Consider clindamycin 300 mg PO qid for five to seven days. Warn patients about diarrhea and upset stomach. Diabetic patients may need extended day coverage. Wound care is mandatory. The patient should not remove or get the dressing wet for the first 24 hours. Then, dressing changes can be completed once a day or as needed. Pain medication should be taken prior to dressing changes. Follow-up should be within three to five days. Pain medication should be given to the patient because digital blocks wear off quickly. Sutures of the replaced nail are removed in seven to 10 days if the patient is followed in the ED. A totally avulsed nail, if replaced, may grow normally, but a new nail will push out the repaired nail. The old nail can be removed in two to three weeks once the eponychial fold has new nail growth. The nail bed may be uncovered for a few weeks if the replaced nail is removed, but this area dries and become less sensitive. It is important to keep this nail bed clean as the new nail grows over it.

CautionsThis patient did not suffer any tendon involvement, but it is important to examine the patient for tendon injuries and follow up with a specialist. Patients often need to be taken to the operating room for exploration and repair if they have complicated injuries. Consult your hand specialist if you suspect tendon involvement. Use a thumb spica splint for flexor or extensor tendon injury to the thumb. Immobilize the entire hand and wrist using a dorsal splint for flexor tendon injury to the finger. Use a volar splint from forearm to fingertips for extensor tendon injury to a finger. Note: A patient may have an ulnar injury, not a tendon injury, if he cannot extend the PIP and DIP joints of all fingers (but does not have lacerations to each finger). (Semers NB, Practical Plastic Surgery for Nonsurgeons, 2nd edition, New York: Author’s Choice Press, 2007.)

Tip of the WeekAs you may already know, some antibiotics such as cephalosporins and penicillin can increase the rate of bleeding by increasing the INR in patients who are on warfarin. It is important to take a full history, and ask patients about their medications, no matter their presenting problem.

Go GreenHave you ever noticed a piece of hospital tape stuck to your shoe, and then found it just wouldn’t budge when you tried to remove it? And one week later, it’s still there? Leftover hospital tape is great for all kinds of home projects! It’s strong, durable, and sticky. It’s good for patching things, painting projects, and can be used at the base of your door to prevent drafts. You can use it to fix a shoe, too. Offer it to your patient first, but if you were going to toss the extra tape, save it for a project and reuse it!

Dr. Roberts is the chairman of emergency medicine and the director of the division of toxicology at Mercy Catholic Medical Center, and a professor of emergency medicine and toxicology at the Drexel University College of Medicine, both in Philadelphia. He is also the chairman of the editorial board of Emergency Medicine News, and has written InFocus for more than 25 years. Ms. Roberts is an acute care nurse practitioner at Inova Fairfax Hospital Emergency Department in Falls Church, VA. Read their blog, The Procedural Pause, at http://bit.ly/ProceduralPause.

This is what you signed up for, right? A career where you are a multitasking, highly-skilled medical practitioner in a fast-paced emergency department. This place is predictably unpredictable, but you are saving lives, and it feels good! The problem is, you cannot help feeling unappreciated, underpaid, overwhelmed, and exhausted. You are finally living the dream, but the dream consists of working weekends, double-call, and every other holiday. You miss lunch while still gaining a few pounds. You gain incredible insight into a very broken care system. Feeling more like a nightmare? It’s certainly not what you expected.

Now you have to deal with demanding patients who expect customer service perks. The patients who say, “Do more tests,” and insist on instant gratification. The audacity! You are frustrated that your clientele is telling you how to do your job. The degree behind your name means nothing because Google has allowed your patient to complete a self-diagnosis. This place is for emergencies, not primary care. These complaints are not emergent at all.

You feel justified by your disdain because you are not alone. Your colleagues exchange glances when a patient demands a head CT, or you hear a deep sigh from a co-worker when a patient asks for a stat MRI for back pain he has had for eight years. The nurses agree that your narcotic-seeking patient is simply that, and needs security to escort him out. Mr. Jones is back again for a refill of his blood pressure medication. Now you see one more person just signed in with a stubbed toe.

This is not what you signed up for at all. Breathe. Stop for a minute and regroup. Now, slap yourself. Maybe you need to slap yourself twice. This is what you signed up for! The ED is not just for emergent concerns. It is a care center where people know there are doctors and nurses. It is not just for emergencies like strokes, MIs, and blunt trauma! It is for patient care, in general, and their satisfaction. Until you realize patient satisfaction is part of the care plan, then you are going to continue to live a miserable existence in your department. Let us explain.

Back when organized medicine was — wait a second — has it ever been organized? No. Never. There are buildings with roofs, medications, tools, and machines that help you make decisions, but it’s not exactly organized. The ED is full of chaos. What about resources — or lack thereof? Your local resources exist, but most of the time they are almost impossible to utilize. Now, add the following fun facts: Your patient may not be able to read or write or speak English. He might be elderly or broke. When these types of patients ask you for a helping hand, why do you act so annoyed? We all know your badge doesn’t say S. Smith, Waiter. It doesn’t say J. Jerk, either.

Your badge says Emergency Physician or Nurse or Physician Assistant or Nurse Practitioner. This role is more than knowing how to diagnose and treat heart failure or catch early sepsis. This role is about providing total patient care and making people feel better, even the ones who don’t quite get it. It is about making people happy and motivated to play an active role in their own health care. After all, a happy patient trusts you, and isn’t that what this is all about?

Recent personal opinion columns scold and mock our demanding patients and hospitals that stress concern about patient satisfaction scores. Most of these rants reiterate the same themes about non-emergent patients demanding non-emergent testing or treatment. Many ED providers complain that patients don’t understand our overwhelming jobs, and visit us with complaints that should be seen somewhere else. Well, the ED is that somewhere else.

Providers whine that nonsensical satisfaction scores should not be part of our job evaluation. The patient’s opinion should not be a factor or used as an evaluation tool. Nonurgent patients should understand we are busy with other emergencies, and they need to wait. This may be true, but we don’t need to broadcast to them that maybe they are not as important. We also don’t get to say their patient satisfaction scores simply don’t matter, that only the admissions’ and critical patients’ scores are read.

It’s controversial. Patient satisfaction, however, is important in the ED and so are the scores — to an extent. What people think about your care should matter to you and your facility. It should be measured and monitored. You should want to change your practice based on negative feedback.

Also important are refills, toe pain, dental pain, and well checkups. The ED is not just for emergencies, and it will always be that way. It doesn’t matter what a patient’s needs are; you must provide aid. The challenge is not the difficult intubation or rushing a stroke patient to the CT scanner within the window. Those steps are easy for you because they define your job. The real challenge is to accept that the ED will never be what you want it to be or operate the way you see fit.

It is also a challenge of your character. Patients are going to remember you, and their opinion matters regardless of who they are and what their complaint is. Their opinion should also matter to you because this also defines your job. This should not be seen as a chore but as a job that you want to master. You may yearn to explain to people what constitutes a true emergency. In the end, though, whatever brought them to the ED is an emergency to them, and they need your help. Your definition doesn’t matter.

As ED providers, we prioritize. Most days, we make a difference and people appreciate our efforts. Other days, we see demanding patients who are not as privileged with our educated minds or who do not have the financial solution to their health care needs. We must accept that the ED is a mixing bowl of complicated cases and part of our job is to find a recipe that works for each patient. The ED is a place for compassion and creativeness, not for complaining, personal bias, or judgment.

No, we do not have to prescribe antibiotics for every cough or runny nose to boost our scores. Not every patient gets a CT or an x-ray just because he asks for it. Providers seem so annoyed by the requests. Find a middle ground with alternative options if you can. Considering patient satisfaction as a goal is not giving in to Press Ganey. It is important to reexamine how you practice and how you treat people, even the incredibly ill-advised ones. As providers, we are still allowed to exercise our clinical judgment to make a decision about patient care and not get irritated at patients when they ask for or demand things. Do not lose sight of creating a relationship through communication, trust, and ultimately, kind rapport. Don’t fall into the I’m-the-provider-and-I-know-best mentality. We can explain our thought process to patients and reassure them about our decisions whether to do testing.

Our jobs as ED providers include saving lives, but they also include considering patient satisfaction. These scores should not be exempt just because we make life-or-death decisions. Our profession should be respected and some patients need to wait, but being callous is never justified. Maybe we can look past the initial insults of certain patient complaints and find a deeper meaning. Not all of the scores are accurate or reflect the total picture of who we are as providers. No one is perfect, and we should accept that there is always room for growth and change.

We have a privileged job, but it does not mean we are allowed to be pompous. Patient satisfaction, courtesy callbacks, answering questions, and going the extra mile not only make a difference to our patients, they define our role as care providers. Rolling our eyes at our regulars will not make them stop coming. The next time you feel yourself wanting to say, “That is not my job in the ED,” think again. It is your job, and it is going to keep being your job. Consider patient feedback realistically. Treat everyone with compassion and courtesy, and I guarantee the rewards will not be what you expected.

Olecranon bursitis, also called baker’s or Popeye elbow, can be a painless or an irritating condition involving the bursa located near the proximal end of the ulna in the elbow over the olecranon. Normal bursae sacs generally are filled with a small amount of fluid, which helps the joint remain mobile. The sac can swell under the soft tissue from overuse or when the area sustains an injury from a bump or fall.

Normal bursae are usually small, but they can grow to be quite large, swollen, and occasionally even infected when they become irritated or inflamed. The swelling is obvious because the space in this area is limited, and drainage of the fluid may be necessary. Physical examination of patients with uninfected olecranon bursitis demonstrates an annoying but supple lump on the posterior elbow; it is unsightly yet only minimally symptomatic. It may have even gone away by itself in the past. Infected bursae usually reveal a warm, red, quite tender, and painful bulge over the elbow with limited range of motion. Patients feel most comfortable in the flexed position and have difficulty extending their elbow because of the pain and swelling.

Most aseptic/sterile swellings are merely cosmetic and not especially bothersome. Many come from resting the elbow on a bar while drinking. Recurrences are common after simple drainage. Very red, hot, and painful bursae enlargement usually means gout or an infected bursa. Infected bursa must be drained and treated with antibiotics, and a cure is not always easy. Infected bursae demonstrate less floppy swelling and more diffuse redness and tenderness.

External soft tissue view of the left elbow. (Photo by Martha Roberts)

This patient had nonseptic olecranon bursitis. (Photo by Martha Roberts)

Radiographic views of the left elbow. The left lateral elbow shows moderate soft tissue swelling over the olecranon without bony injury, left. The left AP view of the elbow shows that the IV line was inappropriately placed in the affected arm. (Photos by Martha Roberts)

The Procedure• Premedicate patients who may require analgesia.• Place the patient in a position of comfort with the affected elbow within your arm’s reach. Effective positions include allowing the patient to give himself a hug by placing the arm across his chest or having him lie on his unaffected side with his elbow propped over a large drape.• Place your US probe over the affected area and assess for the highest area of fluid collection. Mentally note this area using landmarks, and remove the probe once located.• Apply antiseptic to the site. Apply sterile gloves.• Inject 1-2 mls of 1% lidocaine using a prefilled 25g needle to anesthetize the affected area.

• Remove the 25g needle, and wait one to two minutes.• Insert 18g needle attached to 10 mL syringe to same entrance site, and begin draining the fluid from the bursa sac. Use a sterile technique. Consider using sterile US probe covers.• It may be necessary to “milk” the area of fluid to help drain the site as you pull back on the syringe.• Remove the 18g needle once aspiration is complete, and apply a BandAid or dressing. • Send a specimen of the fluid to the lab with appropriate orders.• Apply an ACE wrap over the site for compression, and offer the patient a sling for added support.• Remind patients to do shoulder exercises if a sling is applied to avoid frozen shoulder complications. Do not splint the extremity.• Arrange orthopedic follow-up within 24 to 72 hours and strict return precautions.• NSAIDs are the treatment of choice for pain and decreased swelling. Oral steroids are not indicated.

Approximately 5 mLs of clear, yellow fluid were removed from the bursa. No blood or pus was noted. Results were properly labeled and sent to the lab. Occasionally this sterile fluid is blood-tinged. (Photo by Martha Roberts)

Septic bursitis usually results from a traumatic bony injury, and a wound or cellulitis will most likely be associated. Literature review reflects that more than 70 percent of septic arthritis cases are related to traumatic injury. (Roberts & Hedges. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.) Consider your high-risk populations to be those who are immunocompromised, diabetic, alcoholic (chronic injury or fall), or have jobs that may involve crawling on elbows or forearms.

Pus or cloudy discharge will be present on bursal aspiration, and is used to make a bedside diagnosis. Cell count may be more than 200,000 per mL. Gram stains may be negative about 30 to 50 percent of the time, even with septic bursitis. Cultures may reveal Staphylococcus aureus (80%) or streptococcal organisms; gram-negative cultures are rarely seen. (West J Med 1988;149(5):607.)

Septic bursitis does not always present with a fever. (Roberts & Hedges, 2014.) Treatment of septic bursitis for successful outpatient therapy (not diabetic or immunocompromised) includes clindamycin 450 mg PO three times a day for one week or Bactrim 2 DS tabs PO twice a day for one week. IV antibiotics such as vancomycin, clindamycin, and linezolid are given for severe cases during inpatient management. Remember, low WBC count and negative gram stain do not rule out infection. (Levine B. EMRA Antibiotics Guide. Emergency Medicine Residents’ Association, Irving, TX: 2012.)

Nonseptic bursitis may result from a gouty attack or arthritic flair. Drainage will be yellow-tinged or straw-colored but clear. It may also be slightly blood-tinged, and may have an erythrocyte count of 20,000-30,000 per mL. The leukocyte count may be 10,000-20,000 per mL, but is rarely high. Crystals may be seen and give rise to suspicion of gout. Overall, the cell count will be less than 6,000 per mL for nonseptic bursitis. (McAffe & Smith, 1988.)

Cautions

• Is your patient on blood thinners? You can still drain the bursa carefully. But make sure he is not taking over-the-counter medications that could be an issue if he is also taking Coumadin, ASA, or Plavix. Glucosamine sulfate, a popular but controversial supplement for treating osteoarthritis or inflammation, may be something the patient uses. You may want to advise him to avoid vitamin C and Omega 3s as well.• If patients are looking for an “organic” treatment, suggest acupuncture, physical therapy, or massage. Always suggest orthopedic follow-up, however, as primary advice.• What is the bigger picture? Olecranon bursitis may be caused from a lupus flair or uremia. Be sure the patient has proper follow-up. It doesn’t hurt to consider warning signs of other systemic diseases besides gout or arthritis.• IV placement: Do not place intravenous lines in the affected arm if at all possible. As noted in the image above, the nurse placed a line in the arm with the known injury. The patient needed pain medication during the procedure, and it was difficult to administer because of positioning. Discuss this with your team if you are ordering labs or need IV access.• Bursal aspiration: We all know your first thought may be to get rid of that sharp quickly! Don’t forget, however, that you need to send what you drain to the lab! Be careful with your fluid-filled syringe after you drain the bursa pocket. Do not recap the needle. Instead, immediately transfer the specimen to your sample containers and send it to the lab.• Are you cleaning your ultrasound machine appropriately? This is as important as doing the procedure itself because we can’t do our jobs effectively without the right equipment. Be careful what you use to clean the machine because heavy cleaners or abrasive pads such as CaviWipes may cause irreversible damage. Remove gel from the transducer immediately after use with soft gauze. Refer to your specific model’s requirements for appropriate cleaning guidelines, but keep in mind a neutral pH is best.

Tip of the WeekOur friend Eugene Lee, MD, at Inova Fairfax Hospital ED reminds us that an open dialog with our orthopedic team is important and necessary. Previous treatments of bursitis should always be taken into consideration; chronic olecranon bursitis needs close follow-up. The orthopedic team should be consulted if you are at all considering injecting steroids into any bursa, especially if the bursa was recently or previously drained or a septic joint is suspected. Ruling out septic bursitis is imperative before injecting steroids into any bursa.

Some studies say, however, that 20 mg intrabursal injections of methylprednisolone acetate may be an effective treatment regimen for nonseptic olecranon bursitis. (Arch Intern Med 1989;149[11]:2527.) Please take into consideration, however, that the literature review of these data is limited because of sample and study size as well as inconsistent results. More information on this topic is welcome, and we encourage your comments!

The Approach: How to Help HealWe promised you some information about soft tissue injuries, and you’ve got to hand it to us: we delivered! Last month, we discussed incision and drainage of large burns to the hand. Review it here before reading further: http://bit.ly/RobertsBurn. This month, we want to take an in-depth look at wound care management for burns and highlight other pearls needed for top-notch healing.

You should try to follow a few simple rules when it comes to treating burn patients. Soft tissue skin injuries heal in stages and are dependent on direct and correct treatment of the area, nutrition, and hydration. Most providers fail to mention the benefits of protein and fluid intake to burn patients, especially if they are minor injuries. Nutrition and hydration play a major role in the healing process along with keeping the area clean, dry, and properly bandaged.

Be sure to familiarize yourself with the proper essential wound care materials: What is Kerlix? When do I use Xeroform? What type of splint is best? Know where things are in your emergency department stockroom. Actively involve and engage your patient in managing his burn care during your first application of the bandage. Print proper written instructions reiterating the information with phone numbers for local burn centers and specialists. Provide pain management, and take time to answer the “dumb question.” Infected burns are painful and can be debilitating, not to mention that patients are worried about the cosmetic appearance. Complications can be avoided if you spend the time talking to your patient about how to treat his injury properly.

The Procedure: Assessing the Damage and Treatment EssentialsOur previous hand injury is a great example of a volar hand burn that needs a bulky dressing and splint.

Other injuries include dorsum burns, treated in similar fashion with full debridement.

How to treat the blister is always a question for all burns. Preserve the skin and use it as a protective barrier for the first 24-48 hours for volar hand burns. After that, however, the wound requires debridement, and all dead skin has to be removed by our favorite local artist, the hand surgeon. The burn to the dorsum of the hand was debrided on the initial visit and treated in a similar fashion, with close follow-up. Here is a step-by-step approach on how to apply the proper dressing for this type of burn, which can be modified for any extremity burn depending on the affected area. Examples of burn dressings:

Provide necessary tetanus vaccination or booster.

Ensure that the patient has been adequately medicated for pain.

Provide a layer of gauze padding to the debrided sites when applying your bulky dressing. It’s key to have the gauze draw fluid away from the burned surface during healing.

Cover all affected areas with liberal but even amounts of your chosen barrier and healing cream (sulfadiazine/Silvadene for larger burns, bacitracin for smaller ones, etc.). Some apply an Adaptic pad or Xeroform to the affected areas before using gauze. Wet gauze sticks when the dressing is changed; this can also help with secondary debridement.

Note: Separate all fingers with gauze pads (A). This was not done in figure D, and skin maceration of normal skin occurred.

Tell the patient to make his first dressing change in 24-48 hours.

Start applying bulky dressing wrap. Do not apply a splint directly to the injured area without a bulky dressing barrier!

Apply a volar splint (for this burn because it is a palmar burn) or thumb-spica-like splint to accommodate injury. Be sure to have it in a dependent position where fingers are able to move freely if at all possible. The splint serves as a protective garment and skin stabilizer as healing occurs over the next seven to 21 days.

Discharge Paperwork ConsiderationsProvide your patient with written instructions for dressing changes at home:1. Time your dressing change for half an hour after taking your pain medication.2. You may need someone to help with your dressing changes.3. Prepare all materials before you get started.4. Remove all parts of the old dressing and remove or wash off the prior cream that was applied with liquid soap like Dove or Dial.5. Inspect the area. Is it infected? Look for redness, swelling, warmth, and streaking. Some dislocation and discharge may be normal. Excessive amounts of either are not normal.6. Perform range-of-motion exercises in the same ways you would use your hand, foot, finger, etc.7. “Fluff up” your gauze by pulling at it slightly and stretching it before applying.8. Apply the new ointment or cream with a sterile tongue blade or piece of gauze.9. Apply “fluffed up” gauze. Do this in a bulky dressing style, as shown to you in the emergency department.10. If you have a splint, apply it after.11. Wound care is done daily.(This list was adapted from “How to Change a Burn Dressing at Home: Patient Instructions” from Roberts & Hedges, Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)

Cautions: Focus on Nutrition and HydrationThe past few decades of intense burn research prove that wound care, nutrition, and hydration are the keys to successful healing regardless of burn size or shape. The Journal of Parenteral and Enteral Nutrition knows a thing or two about nutrition and metabolic support. Evidence-based results for burn care support good nutrition, even for minor burns. A noted improved clinical status and decreased healing times are seen with low-fat nutrition in all types of burn patients. Low-fat nutrition, for example, decreases rates of infection and shortens overall healing times. Fish oil did not show any added clinical benefit. Overall, monitored nutrition during healing times for patients with burns can help modulate cortisol binding globulin and free circulating cortisol after severe stress. (J Parenter Enteral Nutr 1995;19[6]:482.)

A study in the British Journal of Nursing said disregarding nutritional status for burn patients may compromise healing times or prolong the stages of wound healing. Fatty acids are essential for cell structure, and play an active role in the inflammatory process. Increased levels of protein are necessary for collagen formation when the body is attempting to heal, and this also helps prevent wound dehiscence. Some studies show vitamin C also plays a role in the healing process, and it could be an added supplement. Vitamin C deficiencies can also contribute to fragile granulation tissue. Finally, some evidence suggests that low albumin and body mass index (BMI), adequate rest, and even some holistic approaches are essential for healing. (Brit J Nurs 2001;10:[1]:S42.)

Finally, it is well known and accepted that fluid replacement, even for minor burns, is essential to wound healing. Several approaches help determine the needed amounts of fluid resuscitation for burn patients. These rules do not apply just for inpatient admissions. Hospitalization should be considered if you are thinking of aggressive fluid resuscitation management for a patient. The Rule of 9s and the Parkland formula are good standards to review and practice when you are concerned about a burn patient.

Do not forget to tell patients with minor burns to increase fluid intake and avoid dehydration. This should be standard practice for all your burn patients. Encourage a balanced, high-caloric diet free from saturated fats and with increased protein intake over the next 48-72 hours. Also discourage high sodium and sugar intake for the next week. As noted, multivitamin supplementation is still debatable for many ailments, but vitamin C is an organic and inexpensive holistic approach. Be sure to note that aloe and honey are acceptable and affordable forms of topical healing agents, but manufactured creams like Silvadene and bacitracin are still the go-to topical treatments.

Tip of the WeekHaving a hard time getting the gauze to wrap around the thumb? Cut a hole in the middle of the gauze wrap, and let it slide over the thumb just like the way you would put a T-shirt on over your head. The gauze remains uninterrupted, and you can continue to wrap the extremity. This will help keep the dressing in place, and doesn’t allow the gauze to roll up over the thumb and expose open skin that could let in bacterial intruders that could cause infection.

Go GreenYou opened a pack of sterile gauze, and only used one piece. Your instinct is to just throw away the rest because the patient is leaving and doesn’t need any more gauze for his wound care. Send the extra home with the patient! He can use the nonsterile part on the outer surface of the bulky dressing.

Hand burns from thermal injuries are common chief complaints in the emergency department. Sometimes, 2nd- and 3rd-degree burns may need immediate interventions and warrant special attention. These injuries are painful, and often have associated complications such as permanent scarring, cosmetic issues, prolonged pain, and even infection. ED providers can assist with the primary complications related to blistering of the hand or extremity. Careful follow-up and a detailed discharge plan produce better outcomes and minimize overall complications. Full body/surface burns or circumferential burns should always be seen and evaluated by a local burn center. Burns related to alkaline, gas, fire, poisons, and chemicals may require expert consultation and possible admission to the burn center.

The patient’s burn featured in the photos below occurred about 48 hours before ED arrival. The patient, a chef, accidentally placed his hand on a hot flat-plate grill while cooking in a restaurant. The initial burn surface was not swollen or raised, but it began to swell uncontrollably over 24 hours. The swelling fluid pocket produced significant pain and restriction of the first digit. The patient came to the ED hoping we could drain the site and preserve the soft tissue of his hands.

The American Society for Surgery of the Hand (ASSH) classifies burns into four categories: 1st degree: superficial, redness of skin without blisters; 2nd degree: partial thickness skin damage, blisters present; 3rd degree: full thickness skin damage, skin is white and leathery; and 4th degree: 3rd degree with damage to deeper structures like tendons, joints, and bone. (http://bit.ly/HandBurns.) Classification of burns is also based on three criteria: depth, percentage of total body surface area, and source of the injury (thermal, chemical, electrical, radiation). (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th ed. Philadelphia: Saunders/Elsevier, 2014.) It is important to complete an accurate evaluation of every burn patient in case fluid resuscitation or transfer to a burn center is necessary. More information about how to categorize burns can be found on the American Burn Association website at www.ameriburn.org.

The initial ED management blisters from burns, however, is controversial. It likely doesn’t matter exactly what is done. Traditionally, large blisters are left intact to help with pain relief, and small or broken blisters are debrided when first seen. Blistered skin will eventually have to be removed, and skin grafting may be required. All burns are different in size and shape and healing times may vary, but smaller more manageable wounds are usually watched carefully and not aggressively debrided on initial presentation. The blister in this case, however, warranted drainage. The patient will need to follow up with a plastic surgeon or hand specialist within a day or two. Actual treatment is based on the severity of the burn, potential for complications, and availability of follow-up.

Needle aspiration of blisters should not be performed with overlying skin that has not been debrided for more than a few days because this increases the risk of infection (UpToDate [2014]. “Treatment of Minor Thermal Burns,” http://bit.ly/1powgJT.) Each hand only makes up 2.5 percent of total body surface area, but loss of function and pain from a burn is 100 percent maddening.

Aspiration of the blister two days after the ED presentation with the skin left intact. This flap of skin will need to be debrided in a few days.

The Approach• Wound care with simple hand washing and cleansing• Gentle incision and drainage of the site• Coverage of wound with ointment and bulky dressing• Splint care and pain control• Follow-up with plastic surgery or specialist in one to two days

The Procedure• Medicate the patient appropriately with either PO or IV medications prior to starting any procedure after evaluating the initial burn. Burns are quite painful injuries.• Instruct the patient to sit on a stretcher while you inspect the burn.• Consider consulting a hand specialist prior to beginning. Typically, the ED provider can drain burns of this size and caliber (such as the one featured in this photo) at the bedside.• Clean the area with Betadine or antiseptic. Gentle hand washing is also encouraged prior to treatment.• Sterile gloves are not necessary, but they are not a bad idea.• Use an 11-blade scalpel to make a 0.5-1 cm incision at the base of the burn. It is best to make the incision to an area of the burn where flexion or extension is at its least resistant. The incision was made at the base of palm, just distal to the wrist, in this case.• Note: Local anesthesia is not typically indicated for the initial I&D of a burn. The patient’s skin is the most painful under the burn, and future pain is usually caused by drying or peeling/pruritus of the skin flap that remains over top of the burn. The drainage incision is also small and should not cause significant pain. Do not make a large incision if you are choosing to leave the skin flap in place.

• Slowly allow the fluid pocket to drain into a basin. Do not rush this evacuation. Gently massage the skin to evacuate the fluid. It may take two to five minutes to completely drain the area, depending on the size of the burn.• We suggest initially leaving the deflated skin in place as a protective cover for the burn once the area is mostly drained and flattened. Complete debridement of the burn with removal of the skin is controversial, but all tissue must be removed eventually. (Roberts & Hedges, 2014.) Discuss your decisions with the patient based on your consult with plastic surgeon on call.• Cover the area with ointment. Bacitracin and silver sulfadiazine (Silvadene) are fine choices. A thin, moderate layer is used. Silvadene has broad gram-positive and gram-negative antimicrobial spectrum coverage including B-hemolytic strep, Staphylococcus aureus and S. epidermidis. It may also cover pseudomonal infections, so it may be the better choice for diabetic patients or immunocompromised patients. (Roberts & Hedges, 2014.) Antibiotics are not initially given.• Apply a bulky dressing and splint. Different variations of the thumb spica or radial gutter splint may be used best for palmar burns. Burns to the dorsal surface may do best with a volar splint.• Give a supply of pain medication because the patient may experience increased pain from the site as the skin dries over the next 24-48 hours. Tell the patient to take pain medication half an hour before dressing changes. (Roberts & Hedges, 2014.) Pruritus is often a common complaint, and can be treated with over-the-counter Benadryl. Warn the patient to return to the ED for complications such as black or ecchymotic changes to the skin or even associated cellulitis or lymphangitis. Stress that the dressing should not be constricting and that the splint needs to be worn for proper healing.

Cautions• Remind patients not to soak their hands in water or ice water. This causes further damage to the soft tissue. If the patient arrives at the ED with his hand soaking in a bucket, have him stop immediately.• Take any jewelry or restrictive clothing off immediately. Rings and bracelets must come off with a ring or jewelry cutter if attempts by the patient fail.• IV pain medication is often necessary so do not hesitate to medicate these patients quickly and appropriately.• Cleaning the area with gentle soap and water is necessary to avoid infection.• The patient should never scrub the area pre- or post-procedure because this will further damage the skin.• Antibiotic ointments such as bacitracin or Silvadene are acceptable post-burn ointments. Patients should avoid holistic approaches like toothpaste, butter, herbs, or sprays because they can cause further damage to the soft tissue. (Medscape [2014]. “Emergent Management of Burns,” http://bit.ly/1poP7nX.) Of note, Silvadene is contraindicated for term pregnancy and in newborns because of possible induction of kernicterus. (Roberts & Hedges, 2014.)• Bulky dressings are helpful, but can often stick to the burn and cause more pain, especially with removal. Review wound care and approaches to dressing changes with the patient prior to leaving. Demonstrate how to apply appropriate layers of bacitracin or Silvadene with appropriate dressings prior to discharge. Gentle, cool water rinses can be used to help with dressing removal at home.• Elevate the extremity while at home whenever possible (UpToDate.com, 2014.)• Update tetanus as needed.• You also should consider admission if you think a patient warrants PO antibiotics for potential or existing infection!• Finally and most importantly, a circumferential burn of any limb can sometimes constrict it like a tourniquet. The constriction must be controlled or “released” with an escharotomy if this occurs. (American Society for Surgery of the Hand, 2014.)

Tip of the WeekWe know we said holistic approaches for burn treatments should be avoided, but aloe vera cream may be an inexpensive and useful treatment for smaller burns. Honey may also be used on the burn because it has been proven to provide antibacterial and anti-inflammatory properties. Oral corticosteroids, however, are not useful. There is “no role for topical steroids in the initial treatment of minor burns, as this may increase the risk of infection and impair healing.” (UpToDate, 2014 and Roberts & Hedges, 2014.)

Wound care and suture repair are two of the most frequently encountered issues in the emergency department. It is the midlevel provider’s job to be familiar with proper wound care and suturing techniques as well as quick and safe treatment of soft tissue skin injuries. You can use various suturing techniques and styles, but it is important to find a few that really work for you, often tailored to the area of injury.

This month, we are focusing on lacerations and puncture wounds to the soft tissue of the face. Future posts will touch on other suturing skills, with some great tips from our plastic surgery friends. More in-depth posts will include videos of nerve blocks to the face, which are incredibly useful for wound repair. We will also touch on nasal, buccal, and ear lacerations as well.

The face has a plentiful blood supply. Primary closure is important for facial lacerations to avoid unnecessary scaring. Sometimes, swelling or extensive facial tissue damage makes primary closure more difficult. Careful wound cleaning of facial lacerations is critical. The soft tissue of the face is not at high risk for infection, but removing foreign bodies and cleansing with antibacterial agents is paramount. All wounds should be cleaned well and closed within a four- to six-hour window. Wounds older than six hours or presenting the day after the injury can be repaired, but a plastics consult may be warranted. (Semers N. Practical Plastic Surgery for Nonsurgeons. Philadelphia: Authors Choice Press, 2007.)

Case StudyMr. J fell down the stairs of one of Washington, DC’s busy Metro stations. He fell face first, and the frame of his glasses became embedded in his face. Mr. J could not remove them and neither could EMS personnel. The glasses were then tapped to his face to help keep them positioned without ripping his skin further until our providers in the emergency department could complete an evaluation.

The Procedure• Consult your on-call plastic surgeon if you have any questionable areas of repair.• Consider early pain management interventions for this procedure. Percocet or Vicodin are good PO choices. IV morphine or Dilaudid may be needed for more extensive injuries and pain. A small dose of Valium or Ativan may also help your patient relax after the emotional and physical pain these injuries can cause. Local anesthesia administered promptly will usually alleviate the need for additional pain control.• Prep. Wash your hands. This is still the primary way to decrease infection rates for all procedures. It is a good idea to practice sterile technique for the majority of ED procedures. Sterile gloves have not proven to decrease infection rates, despite what your predecessors may have taught you. (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition. Philadelphia: Saunders/Elsevier, 2014.) Masks and eye protection should always be donned.• Anesthetize. Local anesthesia to the site of the laceration can be used before or after removal of the foreign body. Anesthesia may be considered when and if the foreign body is deeply lodged in the skin. The best choice of local anesthesia is buffered lidocaine with epinephrine. The only time lidocaine with epinephrine is contraindicated is when the wound is a flap, raised by the injury. (Semers, 2007.) Plain lidocaine is a better choice for facial flap injuries because you do not want to compromise circulation to the flap.• Investigate. Inspect the area for any smaller foreign bodies once the larger objects have been removed. Complete removal of all debris, wood, dirt, and objects must be done. Also look for bone involvement. Obvious dead or dark tissue can be removed carefully.• Clean. Jet lavage is the proper irrigation procedure to use, but excessive spraying can cause further tissue damage. Be gentle but thorough. A mixture of Betadine and normal saline is a good agent for cleansing.• Note: Antibiotic solutions have not been defined as a standard practice.• A 20-gauge angiocatheter used at the tip of the irrigation device is good for removing most debris. Copious normal saline or tap water can also be used. DO NOT put an irrigating catheter into a puncture wound; it disseminates foreign material and cause tissue swelling, but rarely provides wound irrigation. A hemostat spread open inside the tract helps to separate a small laceration to facilitate wound irrigation.• Apply firm pressure with gauze for two to three minutes instead of countless dabs if you have significant bleeding from the injured area after irrigating.• Inspect and examine the whole face, including an ocular exam if indicated. Tend to eye injuries first, such as a ruptured globe or lid laceration. Ear exams are also important because significant head trauma can cause injury to the middle ear. Check for the presence of a hemotympanum and Battle’s sign, which may indicate a basilar skull fracture. A ruptured TM can be a surgical emergency and cause facial paralysis if the facial nerve has been compromised. Consult ENT if you suspect this issue.• Never put your finger into a wound to explore what’s inside! Use ONLY your forceps and tweezers and occasionally x-rays to explore ALL wounds. • Cervical spine injuries may not be obvious because of distracting injuries. A complete CT of the cervical spine and a head CT should be done if the patient has a significant mechanism of injury to the face or neck such as a traumatic fall.• Complete the necessary radiographs and/or CT imaging of affected areas (i.e., orbits, mandible, etc.).

• Prep for your suture repair once the area is clean and dry. Suture choice: 6.0 or 7.0 nylon thread for soft tissue injuries of the face. Running sutures or simple interrupted are good choices for closure. Mattress suturing is NOT indicated for facial lacerations.• Repair all flap injuries first.• Note that sutures on the face are placed slightly closer together, approximately 3 mm apart. (Semers, 2007.)• Cover closed lacerations with a thin layer of bacitracin or antibiotic ointment.• Instruct the patient that suture removal must be done in five to seven days to avoid sutures scars.• Leave the area open to the air or use a dressing. A gauze bandage is indicated if there is an extensive area of injury. Instruct the patient not to wash or disturb the repaired area for at least the first 24 hours (unless following up with plastic surgeon). Then, daily wound care using gentle cleansing of diluted antibacterial soap like Dove or Dial should be initiated. NO scrubbing.• Note that covering the injury with gauze or a dressing not only serves as protection of the wound but aids patient comfort. They may also help stabilize the affected area if the patient is following up with plastics the following day. They also prevent the wound from drying out, which can cause the patient pain as it heals. Wound coverings also help absorb serosanguineous drainage. (Roberts & Hedges, 2013.)• Tip: Consider Adaptic, Xeroform, or Aquaflo petrolatum gauze for better coverage.• Do not use bacitracin after the first 24-48 hours because it keeps the area too moist, and can lead to further scarring or healing complications.• Tell the patient to elevate his head when sleeping and to avoid heavy lifting, bending, or dangerous activities to minimize facial swelling. (Semers, 2007.)• Small puncture wounds are best left unsutured. Even more irrigation is required if they are caused by a foreign body. Infection is common if foreign material is left deep within the puncture, but retained material cannot always be appreciated at the first visit. Be sure to warn the patient of this possibility! (We will discuss human, cat, and dog bite puncture wounds in future blog posts.)• There are no universal standards or treatments for puncture wounds (Roberts & Hedges, 2013), and studies are limited. What is important is ample cleaning of the area. Probing or coring a puncture wound to the face is not suggested. Antibiotic use for puncture wounds to the face is not clearly defined in the literature. High-risk patients (immunocompromised or diabetic patients) may benefit from a short course of antibiotics, but this has yet to be proven.• Update tetanus as needed.

Cautions• Is there any pulsatile bleeding? Be sure to complete your vascular exam and address all issues.• Is the patient a smoker? This will impair wound healing. Smoking cessation advice is always important in the ED.• Did you ask the hard, personal questions about HIV, hepatitis, or other immunocompromised status? Always be sure to use universal precautions with all patients, but especially pay attention to those who are immunocompromised. Diabetic patients may also have wound healing issues.• Was there an injury to the area involving the shoe, clothing, fabric, or other rubber? Bits of material may be imbedded in the wound. It may be required that a puncture in noncosmetic areas be widened into a linear laceration with a scalpel to adequately explore for and remove foreign material.• Hydrogen peroxide is a very weak antibacterial agent. It is toxic to tissues and red cells. Don’t use it, and be sure to educate your patients on this concept as well.

Tip of the WeekThis week we are giving a shout out to Medscape because we know you are all wondering about local anesthesia to the nose! Check out this excellent article by Medscape, and put all your fears to rest: http://bit.ly/1hIMU1K.

Finger dislocations are relatively simple to identify and treat, but ligament and volar plate ruptures are often missed. Radiographs are not always indicated, but are useful in locating the area of injury and noting avulsion fractures. It is important to listen to the patient’s story to identify the mechanism by which the injury occurred because mimicking this mechanism is typically the best way to relocate the joint. Patients typically do not always need local anesthesia or digital block because relocation techniques are quick and can often be done while simply distracting the patient for a second or two. Treatment is dependent on your skill level, comfort, and ability to recognize these injuries.

DIP, PIP, or MCP dislocation can be caused by any kind of significant force to the area such as hyperextenion or flexion, trauma, pressure, or crush injuries. Keep in mind that primarily the IP joints are much more secure than the MCP joints because of the IP joints’ bicondylar arrangement and the fact that the collateral ligaments are tight throughout the entire range of motion. (Medscape, 2014.) Dislocation of any phalanx joint dorsally can cause separation from the volar plate while lateral dislocations can disrupt one or both of the collateral ligaments. Tendon injury and avulsion fractures may also occur.

Figures A, B, and C: Three variants of PIP joint dislocations are depicted. The most common are (A) dorsal and (B) pure volar with central slip rupture, and least common is (C) rotatory subluxation, which is often confused with pure volar dislocation.

The Procedure• After examining the patient, order appropriate radiographs of the finger, not just the hand. Appropriate views include the AP, lateral, and oblique views. Lateral views of the finger allow the provider to see subtle dislocations or avulsion fractures.• Have the patient on a stretcher in a comfortable position.• Digital blocks are not routinely necessary. But if the patient has a laceration, needs extensive wound care, or could benefit from a block, complete this on an as-needed basis. Note: Skin repairs are done after the dislocation is reduced.• Traction method of joint reduction is used to treat the injury.• Distract the patient with conversation while holding the injured area. It helps to make eye contact.• Mimic the path by which the initial injury occurred; that is, slightly exaggerate the deformity that is present.• Pull the finger forcefully and quickly in the opposite direction as you relocate the finger; that is, push the joint back into position.• Complete a full range-of-motion exam and neurovascular checks. Check stability.• Appropriate splinting (see below for a few tips) should also be completed. Splint the finger in a 20-30 degree angle of flexion for two to three weeks. Orthopedic or hand specialist consultation is recommended.• Be sure to ask about tetanus vaccination if there is a laceration or abrasion.• Stay tuned for future Procedural Pause blogs on suture techniques over joint spaces!

Cautions• PIP joint dislocations need closer follow-up because they are more prone to scarring and heal at a slower rate. Central slip ruptures may also progress to boutonniere deformities.• Flexion and extension ability and neurovascular checks should be completed after relocation procedures.• Dorsal PIP dislocations are most common because they occur with bending the finger backward (hyperextension), but beware of volar plate rupture. These may need digital block if injury is extensive. How do you determine if a patient has a volar plate rupture? After completing relocation procedure, the patient will hyperextend with passive and active motion and show laxity.• Volar PIP dislocations are usually uncommon, but should be splinted with full extension for two to three weeks after relocation of the injury.• Lateral dislocations usually are resolved prior to arrival to the ED, but are easily relocated if not. Buddy-taping the affected finger with an adjacent finger is recommended if there is a suspected collateral ligament tear.• Don’t miss DIP dislocations; they can be subtle, especially in the thumb. They require only 10-12 days of immobilization with dorsal splint.• Mallet finger is NOT a dislocation! It is extension tendon rupture. Use a STACK splint to immobilize this joint and allow the PIP to move freely.• Does the patient have tenderness of the medial side of the thumb’s MCP? Gamekeeper’s or Skier’s thumb is from rupture of the ulnar collateral ligament in the thumb at the MCP joint, usually from a forceful abduction. You may not be able to identify this injury fully in the ED so close follow-up is recommended if suspected. Check for instability, tenderness, and swelling. Patients will have issues gripping items in the future if this injury is missed.

Be more concerned about and seek consultation for the following: • Neurovascular compromise• Associated fractures• Open joint dislocations• Ligament or volar plate rupture• Joint instability• Inability to easily reduce a dislocation (Medscape, 2014)

Don’t mess with these! Take a good history.Hand deformities in rheumatoid arthritis. PA radiograph shows boutonniere deformity of the ring finger, Z-shaped deformity of the thumb, proximal dislocation of the first CMC joint, volar dislocation of the MCP joint of the little finger, and ulnar translocation of the carpus. (Lippincott, Williams & Wilkins.)

Tip of the week: Get friendly with your hand specialist on call, if you are lucky enough to have one available. Often you can send him a quick photo of an x-ray or the finger itself via smart phone and ask for a consult. This way, the specialist can follow up with the patient in his office and already know the story behind the injury.

Go green: Did you know a running faucet uses up to five gallons of water a minute? Of course, it is incredibly important to do appropriate and diligent wound care for patients with hand injuries, but consider using a basin first with soap and water to scrub and clean the hand or affected digit. This is also a great time to sit down to explore and examine the patient’s injury. This also helps create a natural bond with your patient and helps ease tension. This beats making them stand at a sink where the lighting is poor and the splatter effect is even worse!

We finish our shoulder dislocation series by paying our respects to posterior shoulder dislocation. Posterior shoulder dislocations are rare, and account for less than 4-5 percent of all shoulder dislocations, but all ED providers should know how to identify and relocate these injuries. Cases of misdiagnosis and even late diagnosis can occur. Early recognition and appropriate management can save a patient from complicated issues related to the dislocation as well as chronic pain.

Anteroposterior (AP) view, left, of a patient with a posterior dislocation. This dislocation may be difficult to appreciate on an AP view because it is not inferiorly displaced and may appear to be in the glenoid fossa. Note that the space between the glenoid fossa and the humeral head does not look normal. The scapular Y view, right, reveals that a posterior dislocation is present. Note that the humeral head lays posterior to the glenoid fossa rather than being centered over it.

The provider will note on physical exam that patients commonly present with a triad of internal rotation, adduction, and flexion. The physical exam, as always, is key; do not rely on films as your only source of information. You will find it quite difficult and painful if you try to abduct or externally rotate the patient’s arm. Various studies reviewed on UpToDate (2013) show that comparing one shoulder with another is not always resourceful because these injuries present bilaterally depending on the mechanism of injury (examples include seizure, electrical shock, falls).

UpToDate also suggests some useful radiographic clues seen on AP films, one being the light bulb sign, where the humeral head is internally rotated that gives it a circular appearance. It actually looks more like a light bulb (hence the name) than its normal club shape. The space is also widened between the humeral head itself and the anterior glenoid rim, the rim sign. Suspect posterior dislocation if the distance is greater than 6 mm. Finally, the rare trough sign may also be seen with posterior dislocation. This is a fracture of the medial head of the humerus. Note that the AP film may not always give enough information so a Y view is always obtained. The Y view should answer whether it is dislocated.

Posterior shoulder dislocation seen on a scapular Y view, left. The anteroposterior view does not definitively show the dislocation. No superior or inferior displacement of the humeral head is seen because the dislocation is directly posterior. The head of the humerus appears to maintain a normal relationship with the glenoid fossa and the acromion process on superficial observation. Definite abnormalities exist on this film, however. The space between the humeral head and the glenoid fossa is abnormal, and the head and neck are seen end on and resemble a light bulb because of the extreme internal rotation of the humerus. It becomes obvious on the Y view, right, that the humeral head is posteriorly dislocated. It projects posteriorly under the scapular spine rather than in its normal location, centered over the glenoid fossa.

Anteroposterior views comparing posterior dislocation, left, and a normal shoulder joint, right. Posterior shoulder dislocation causes internal rotation of the humeral head, which makes the head appear as a light bulb rather than its normal club-shaped appearance. Note that the space between the articular surface of the humeral head and the anterior glenoid rim is also widened, and the overlap between the head and the fossa is decreased.

The Approach• Radiographs are always necessary before and after any shoulder dislocation to assess positioning, success, and possible fracture, despite some recommendations to the contrary.• Pain control and conscious sedation are keys to a successful procedure and happy patient.• Intra-articular lidocaine injection (combined with other analgesia) can be an important component to relocation (see previous blog on anterior shoulder dislocation for refresher: http://bit.ly/1bchPDG).• Traction-countertraction for posterior shoulder dislocation.• Orthopedic follow-up.

Note: Reduction techniques are similar to those used for anterior shoulder dislocation with a twist. Traction techniques are still embraced and are useful. Neurovascular exams and reassessment of your patient remain the same.

The Procedure• Complete an examination focusing on neurovascular status and visual appearance of the shoulder. Be sure to examine both shoulders. Changes in baseline mental status of patients who sustained a seizure, electrical shock, or trauma may be present, and these patients may not be able to express pain. Obtain thorough history.• Obtain complete anteroposterior, lateral (Y), and axillary views of the shoulder. Get ready to complete the relocation procedure if the films are negative for a fracture and you do not suspect nerve or artery injury. Consult orthopedics before proceeding if there are any complications. Note: Elderly patients may also be difficult candidates for relocation, and osteoporotic bones can be fractured with reduction techniques.• Obtain baseline vitals including oxygen saturation. Continually monitor your patient’s oxygen saturation before and after this procedure. Repeat your neurovascular exam if indicated. Numbness on the outside of the shoulder represents axillary nerve compression, which often subsides after relocation.• Give proper analgesia. Use IV medications for pain control and keep the patient NPO until you are sure he will not need surgical intervention. Morphine, fentanyl, or Dilaudid are all fine choices.• Have a sling handy to apply after reduction.• Go in search of several partners. The bigger, the better because we will be using the weight of our own bodies to help relocate the shoulder. You will be applying traction, internal rotation, and adduction to the affected arm so you will need three people. See last month’s blog for pictures of the reduction.• Person 1: You. Hold the patient’s forearm (not wrist) and use traction, pulling the shoulder and arm toward you during the procedure.• Person 2: Assistant 1. Wrap a sheet around the axilla of the patient’s affected arm, and place the patient in a supine position. Wrap the free end of the sheet around your waist. He will simply lean back to apply the countertraction during the maneuver.• Person 3: Assistant 2. Have another person place his hands behind the affected shoulder and apply upward pressure on the posterior aspect of the humeral head.• This entire maneuver may take a few attempts and a few minutes. If it has not been successful in less than five minutes, try adjusting points of traction or move to another technique. Don’t forget to give adequate sedation if the patient is starting to wake up.• Temporarily sling the arm and prep the patient for repeat radiographs if relocation and full ROM is achieved.• Check films for post-reduction fractures and repeat your neurovascular exam.• Keep the arm immobilized with the elbow at a 90-degree angle with slight hand pronation. Repeat neurovascular exams after splint is applied.• Document pre- and post-neurovascular exams.• Follow up with orthopedics in two to three days.• PO Vicodin or Percocet for pain control, although ibuprofen is useful for soft tissue swelling.

Apply traction, internal rotation, and adduction to the affected arm. Instruct one assistant to apply countertraction (with a sheet wrapped around the waist) and another assistant to apply anteriorly directed pressure on the posterior aspect of the humeral head.

Cautions• Did you miss a rotator cuff injury? Don’t. Have the patient follow up with orthopedics. Rotator cuff injuries are best assessed in a week or two week after injury when the pain and swelling has decreased.• Did you miss a clavicular fracture? Don’t be distracted by the obvious injury. Look at the entire film before focusing in on the injury itself. • Don’t want frozen shoulder? Teach your patient the proper exercises to complete once he is in a sling. Usually, a sling is only necessary for two or three weeks.• Was there a cervical spine injury? How about a radiculopathy? Consider nerve injury, especially for those shoulders that dislocate often. Injury to the axillary nerve will cause a weak or even paralyzed deltoid muscle. • Arterial injury? The axillary artery can be injured (rare), so be sure to check and recheck neurovascular status. Be sure to monitor the patient for at least one hour after dislocation to reexamine neurovascular status post-reduction because complications such as nerve and artery compromise can occur after your procedure.

Go GreenThe next time you suture, you will probably have one of those nice blue towels left over. Rarely do they ever get used during the suturing process and are always thrown in the garbage. Next time, separate it out and save it. It’s great to add to your zombie apocalypse stockpile, especially if you feel the need to wax and polish your car, dust corners of your house, or polish your fine collection of silver teapots. These blue towels are very sturdy, and beat a paper towel any day. And it’s a great burping cloth for your newborns!

No series on dislocations would be complete without mentioning shoulder dislocation. Most shoulder dislocations (>90%) are anterior (forward), and it should be noted that shoulder dislocations make up about half of all dislocations seen in the ED. Most shoulders can be relocated easily, while others may frustrate a provider. Associated fractures, artery or nerve compromise, and even rotator cuff injuries can worsen the situation. Relocation techniques can be difficult, and may be physically challenging for the provider and patient.

Acute shoulder dislocation with fracture of tuberosity. (Photo by James Roberts)

This month we will briefly touch on one of the many techniques used to relocate a shoulder, and ask that you try it. We are going to skip the anatomy, and get right to the heart of the matter. If you have not come across a shoulder dislocation (or 100+) in your practice, then you are not seeing enough patients!

Many techniques are available to choose from when confronted with a problematic shoulder. In fact, here is a short (and probably incomplete) list if you need a refresher.• Milch (if you’re in the mood to go apple picking).• Stimson (if your patient is drunk, and you are busy).• Spaso (if you’re an Aussie).• Cunningham (if you like a more soothing, touchy-feely method).• Scapular manipulation (if you have the strength and patience and you have a buddy).• Traction/countertraction (if you have someone to hold the sheet; our personal favorite).• Eskimo (if you happen to be in the woods, and don’t mind getting a little dirty).• Hippocratic (if you’re uninformed or really old). Note: If you are still putting your heel in the patient’s armpit, we are just going to say it: DON’T DO IT.

The most important thing to remember is to choose a method that you like and feel comfortable performing and executing correctly. You must also take into consideration the patient’s comfort level and what has worked for him in the past if he has had prior dislocations. Once you have mastered your favorite technique, try incorporating various new techniques. And, as always, remember to adhere to the same standard precautions when performing conscious sedation in your department.

The Approach• Despite some recommendations to the contrary, radiographs are always necessary before and after dislocation to assess positioning, success, and possible fracture.• Pain control and conscious sedation are key to a successful procedure and happy patient.• Intraarticular lidocaine injection (combined with other analgesia) can be an important component to relocation.• Traction-countertraction for shoulder dislocation.• Orthopedic follow-up.

The traction-countertraction method with intraarticular block is a useful and safe method with a high success rate. It is also easy for providers to complete with assistance.

The Procedure• Complete an examination focusing on neurovascular status and visual appearance of the shoulder. It should appear “squared off,” painful, and with noted deformity. The patient may be seen holding his wrist with the opposing arm to relieve the pain or pressure. You will not be able to complete full ROM exercises if the shoulder is dislocated. The patient will not be able to touch the opposite shoulder with the palm of his hand on the side of the dislocated shoulder.• Obtain complete anteroposterior, lateral (Y), and axillary views of the shoulder. If the films are negative for a fracture and you do not suspect nerve or artery injury, get ready to complete the relocation procedure. If there are any complications, consult orthopedics before proceeding. Elderly patients may also be difficult candidates for relocation, and osteoporotic bones can be fractured with reduction techniques.• Obtain baseline vitals including oxygen saturation. Continually monitor your patient’s oxygen saturation before and after this procedure. Repeat your neurovascular exam if indicated. Numbness to the outside of the shoulder represents axillary nerve compression, which often subsides after relocation.• Give proper analgesia. Use IV medications for pain control, and keep the patient NPO until you are sure he will not need surgical intervention. Morphine, fentanyl, or Dilaudid are all fine choices.• Have a sling handy to apply after reduction.• Fill a 20 mL syringe with 10-20 mL of 1% lidocaine. Use an 18 g needle for the actual injection. Use chlorhexidine prep, not Betadine.• Have the patient sit in an upright position, leaning forward slightly if possible.• Inject the lidocaine slowly into the lateral sulcus. The empty glenoid fossa is usually quite obvious with palpation. Wait approximately 20 minutes for the lidocaine to take effect.• Go in search of a partner. The bigger, the better because we will be using the weight of our own bodies to help relocate the shoulder.• Wrap a sheet around the patient’s axilla and place the patient in a supine position.• Wrap the free end of the sheet around your partner’s waist. He will simply lean back to apply the countertraction.• Meanwhile, wrap another sheet around the patient’s flexed arm and tie it around your waist. Lean backward to apply traction.• If you are able to have a third person in this scenario, it may help by having him loop another sheet over the humerus and pull gently upward and laterally as you apply traction on the humerus. Go slow and steady!• This entire maneuver may take a few attempts and a few minutes. If it has not been successful in less than five minutes, try adjusting points of traction or move to another technique. Don’t forget to give adequate sedation if the patient is starting to wake up.• If relocation and full ROM is achieved, temporarily sling the arm and prep the patient for repeat radiographs.• Check films for post-reduction fractures, and repeat your neurovascular exam.• Keep the arm immobilized with the elbow at a 90-degree angle with slight hand pronation. Repeat neurovascular exams after the splint is applied.• Document pre- and post-neurovascular exams.• Follow up with orthopedics in two or three days.• PO Vicodin or Percocet for pain control, although Motrin is useful for soft tissue swelling.

Cautions• Hill-Sachs lesion? These deformities can occur when the humeral head impacts the glenoid rim during dislocation. It should be noted, but it does not have any immediate emergent treatment if it occurs.• Did you miss a rotator cuff injury? Don’t. Have the patient follow up with ortho. Rotator cuff injuries are best assessed one to two weeks after injury when the pain and swelling has decreased.• Did you miss a clavicular fracture? Don’t be distracted by the obvious injury. Look at the entire film before focusing on the injury itself.• Don’t want frozen shoulder? Teach your patient the proper exercises to complete once he is in a sling. Usually, a sling is only necessary for two to three weeks.• Was there a cervical spine injury? How about a radiculopathy? Consider nerve injury, especially for those shoulders that dislocate often. Injury to the axillary nerve will cause a weak or even paralyzed deltoid muscle.• Arterial injury? The axillary artery can be injured (rare), so be sure to check and recheck neurovascular status. Be sure to monitor the patient for at least one hour after dislocation to reexamine neurovascular status post-reduction because complications such as nerve and artery compromise can occur after your procedure.

Tip of the MonthThis month, we want to salute the http://shoulderdislocation.net/ website. This is your oasis if you want to know everything and anything about shoulder dislocation and relocation. It’s also a great website for referring patients so they can understand the anatomy, procedure, and suggested follow-up for their injury. Most likely it will happen to them again. Plus the name is easy to remember!

Go GreenWhy are you keeping all those lights on? Most emergency departments shut down certain sections of their ED after hours and as more rooms remain empty. If you know a work area will be shut down for an hour or two, turn off the lights and any equipment not being used. It’s a small step, but it can make a difference!

Elbow dislocations are quite painful and often times accompanied by other injuries. ED providers caring for a patient with an elbow dislocation must be sure to properly examine and x-ray patients prior to putting an elbow back in place. Be wary of the associated complications to dislocations including fractures and nerve or artery injury. Soft tissue damage and swelling are also very common.

Acute elbow dislocation.Photo by Martha Roberts

Like many relocations, slow and steady traction and countertraction with your magical and carefully calculated combination of sedation and analgesia is the hallmark treatment. Relocation procedures require a special closeness with your patient that involves trust because they can require brute force. They should always be completed with the assistance of another provider and carefully explained to the patient before starting the procedure. A sling and sometimes a posterior splint may be necessary to assist with the healing and stabilization process.

Orthopedic follow-up is mandatory because this is a major joint injury. Transient ulnar neuropathy, with the findings of altered sensation involving the ring and little fingers, and hypothenar eminence occurs in approximately 10 percent of cases. Median nerve injury occurs less frequently and is characterized by severe pain not relieved by elbow relocation.

Acute elbow dislocation.Photo by Martha Roberts

Note that the Merck Manual suggests that most elbow dislocations result from falls on an extended, abducted arm and are usually posterior in nature. Be sure to ask the patient how the fall occurred to help guide your eye when looking at radiographs. This way you can possibly pinpoint the site of injury on the film and be certain you are not missing a related fracture. Occasionally a painful distracting elbow dislocation can mask signs or symptoms of other broken bones such as clavicle or wrist fractures. Multiple radiographs may be required.

The Procedure• Complete AP and lateral films of the elbow if you suspect elbow dislocation. If the films are negative for a fracture and you do not suspect nerve or artery injury, get ready to complete the relocation procedure. If any complications are present, consult orthopedics before proceeding.• Obtain baseline vitals, including oxygen saturation. Continually monitor your patient’s oxygen saturation before and after this procedure. Repeat your neurovascular exam if indicated.• Give proper analgesia. Use IV medications for pain control and keep the patient NPO until you are sure he will not need surgery. Morphine, fentanyl, or Dilaudid are all fine choices.• Have a sling, splinting care, and ED tech handy depending on the complexity of the injury.• Position the patient in an upright sitting position with his back at a 90-degree angle against the stretcher.• Stand in front of the patient on the affected side. Have the patient encircle your wrist with his hand while you grasp his forearm and put traction on his forearm. Instruct the patient to remain as relaxed as possible. Then have your colleague apply countertraction to the bicep muscle/humerus as you use your traction to pull the forearm away from the patient and toward you as you push the olecranon back into place. You may gently flex the elbow as you guide the olecranon in place. It is helpful sometimes to use a sheet for countertraction because the pressure of your colleague’s hand may be painful to the muscle. The sheet provides equal and soft pressure.• It’s important to remind your patient to not let go of your hand during the relocation procedure if possible. Explain to him that it is sort of like the scene where Leonardo DiCaprio and Kate Winslet are floating on that piece of wood in the ocean after the Titanic sank. If he hasn’t seen this movie, maybe he has seen “Cliffhanger” with Sylvester Stallone and will get the concept. (Watch a clip of that movie here: http://bit.ly/1b2hkcB.)• You will feel a quick jerking motion (which may be subtle) from the patient as the elbow goes back into place. Immediately complete full range of motion exercises gently. If full range of motion is not achieved, suspect medial epicondyle fracture fragment. This requires surgery. If full range of motion is achieved, temporarily sling the arm and prep the patient for repeat films.• Check films for post-reduction fractures, and repeat your neurovascular exam.• Prepare for a long arm posterior splint. Immobilize the elbow at a 90-degree angle with slight pronation. Repeat neurovascular exams after the splint is applied. If it is at all changed from baseline, loosen the splint and recheck. Note, there is a chance of delayed vascular compromise because of collateral blood flow. This is why we observe patients after relocation techniques at least an hour or two before discharge.• Document pre- and post-neurovascular exams.• Follow up with orthopedics in two or three days.• PO Vicodin or Percocet for pain control, although ibuprofen is useful for soft tissue swelling.

You may choose to use Parvin’s Method if you do not have a buddy to help you with the above procedure. Have the patient lie on his belly, draping his arm over the edge of the stretcher. The pressure from the stretcher to the biceps will work in a similar fashion while you complete traction while pulling down to the floor.

Cautions• Long-term problems associated with previous elbow dislocations are common. Associated effusions, tendonitis, pain, joint stiffness, or other issues related to swelling may be an ongoing problem. Brachial nerve or artery damage may also cause long-term complications. You need to discuss this with your patient and be sure he follows up appropriately.• Injury to median or ulnar nerves may occur from stretching, pinching, or compressing the area itself. Neurovascular exams should be completed before and after elbow relocation. The median nerve can be checked by asking the patient to make a “thumbs up” and by asking him to touch the thumb to other fingers. The ulnar nerve can be tested by using the “little finger out” test. Have the patient abduct and adduct the fifth digit out while the palm is facing the ceiling. Then apply resistance and note any deficits.• Open dislocations exposing the brachial artery are serious injuries that need immediate vascular and or orthopedic specialist intervention. These are typically seen with open fractures of the elbow.

Tip of the weekWhen was the last time you washed your lab coat? Did you know that lab coats are one of the main sources of transmission of harmful bacteria from patient to patient in your hospital? Studies have shown that even MRSA is a big-time offender and you are spreading it, probably right now. And with flu season rapidly approaching, be sure to wash your lab coat at least once a week. Yes, we said it: you have to do laundry or go to the dry cleaners at least once a week! Ask your ED if it has a service that cleans the coats as a courtesy. Be sure to keep a backup lab coat in the ED and never let your lab coat lay in a ball or on the floor. Always hang the coat up after use.

Go greenWhat is your hospital policy on email? Some patients notoriously lose their paperwork and some end up coming back just for another copy. Have you thought about sending your patients’ discharge information to them via email? It’s easy. Set up a separate email account just for discharge paperwork (never use a personal account). That way, you can send the paperwork to the patient with his lab results (in case he wants to forward that to his primary care physician). As always, check with your ED chairman and hospital policy to see if this is allowed. And always maintain patient privacy.

The skilled ED provider always takes proper precautions before attempting fish bone removal and preparing for patient discharge. And a sensible provider never sends an anxious patient down river without a thorough exam.

Fish bones are usually slightly waxy, bendable, and sharp. These tiny bones lodge themselves in the throat with a vengeance. Common nesting sites of fish bones include the base of the tongue, tonsils, posterior pharyngeal wall, aryepiglottic fold, or upper esophagus. Late complications of leftover fish bones in the throat may cause airway obstruction or rarely esophageal perforation. The patient is always at risk of aspiration before and during the procedure. All fish bones should be removed immediately. ENT consultation with endoscopy may be necessary if you are unable to locate and remove the bone itself.

The literature is mixed about plain radiographs vs. a soft tissue CT of the neck. A CT scan of the neck is warranted if the patient has dysphagia, is bleeding or choking, or has any other concerning signs and symptoms. You may consider a CT scan if the patient has a negative neck x-ray and his symptoms are severe. Not all fish bones are visualized on plain films, and the anxious patient should not be overlooked.

Photo by Martha Roberts

Photo by Martha Roberts

The common laryngoscope or a fiberoptic nasopharyngoscopy such as a GlideScope are used to assist with this procedure. Don’t get too excited; we are not going to sedate and intubate this patient! These tools aid in better visualization of the throat and leave less room for error. Plus, they allow the provider to open and examine the patient’s mouth and posterior pharynx with a steady hand while they stabilize the tongue.

The Approach• Inspection and imaging of the throat.• Foreign body removal of a fish bone using a laryngoscope or fiberoptic nasopharyngoscopy.• Follow up with ENT.

The Procedure• Position the patient in a sitting position. Spray the throat with a local anesthetic such as benzocaine. You may also use viscous lidocaine.• Physically examine the external neck for point tenderness, palpable masses, or emphysema or crepitus.• Have the patient open his mouth so you can examine the oral cavity and throat closely using nothing but excellent lighting. A headlamp is best if you have one. Tongue blades are a must.• Inspect both tonsils and posterior pharynx while attempting to visualize the fish bone. Most patients will be able to tell you if they feel symptoms more on the right or left side, and they can usually localize the position of the bone.• Order imaging after you have taken a first look. You may or may not see the bone with just the naked eye.• It’s time for attempted removal once imaging has been completed and reviewed.• Usually bones that are in the tonsils and posterior tongue can be easily removed in the sitting position with a tongue blade and hemostat. Place the patient in a supine position and prepare for deep sea fishing if the bone is lower than the tonsils.• Use the laryngoscope or fiberoptic nasopharyngoscopy to examine the patient’s throat. Explain to the patient thoroughly what will happen. It is best to tell him to breathe through his nose and not to swallow. Consider using suction under the tongue to help with secretions. Patients with hypersensitive gag reflexes may need additional anesthetic.• Insert this scope slowly and inspect. This may take two or three attempts. Go slowly and keep your body low as you inspect internally.• Use a hemostat to grab the fish bone once the bone is targeted.• Note that strands of saliva mimic a bone.• Have the patient swallow several times after removal. They should immediately experience relief if the bone has been removed.• The patient may return to a regular diet of solid foods immediately. Have him follow up with ENT in 24-48 hours if he continues to have symptoms. Repeat films are not indicated unless there is strong suspicion for multiple fish bones.

Photo by Martha Roberts

Photo by Martha Roberts

Cautions:• The patient should experience immediate relief if a bone is successfully removed.• Do not send the patient home with solutions of viscous lidocaine; this can be toxic in large doses (>300 mg in 24 hours).• Only about 20 to 30 percent of patients with the sensation of a retained fish bone will actually have one, but you must take this complaint seriously and consider a bone present until proven otherwise.• Most bones get caught in the oral/hypopharynx and rarely pass into the distal esophagus. Many are visible on direct vision, especially in the base of the tongue and tonsils.• No specific sign or symptoms will consistently rule in/rule out a retained bone.• Patients can generally localize the position of the foreign body.• A lateral neck x-ray is of little clinical value in most patients with minor symptoms. A CT scan is the test to order if additional investigation is required.• The patient can be discharged to eat normally and return in 48 hours for a recheck if the direct exam and fiberoptic exam are normal and the symptoms minor.• Aggressively pursue symptoms that persist for more than 48 hours.• Fish bones impacted in the esophagus perforate; they do not dissolve.• It is unlikely for the bone to perforate the stomach lining once swallowed. Be sure to review signs and symptoms of perforation, just in case.• Your patient should follow up with ENT in 24-48 hours for recheck, always.

Tip of the week:Dr. Dan Hermes of Inova Fairfax Hospital swears by using the GlideScope for all fish bone removals in the throat. He says be sure to talk to your patient while you complete the procedure, reassuring him that it will be over soon. Be sure the stretcher is positioned at the right height for you so you can complete a thorough examination when using the scope.

Go green:Check to see if your hospital autoclaves your hemostats. This ancient sterile process allows us to keep and reuse equipment. Don’t just throw it out after you retrieve that fish bone! Plus, they make great back up pliers for your next fishing trip on the lake.

This month, we are switching gears to focus on joint dislocations, their subsequent relocation procedures, and related complications. The first relocation technique, for treating a patellar dislocation, is a fast, uncomplicated procedure that every ED provider should be able to perform without the need for an immediate orthopedic consultation.

The procedure itself is not challenging, but pain management and related injuries can be troublesome for some patients. The concern for additional injuries such as patella fracture, quadriceps tendon rupture, meniscal or ligamentous tears, and distal femur and proximal tibial fractures should be on your radar.

The bottom line: traumatic knee injuries, especially those with a high suspicion of patella dislocation, should be imaged!

Anatomical Chart Company, 2008.

Keep in mind, a patellar dislocation typically occurs when the patella moves laterally. It is quite obvious at first glance. We’d probably even call it a “duh” injury, as in, “Duh, I can see it’s obviously not right.”

Patellar dislocations may occur frequently in the pediatric patient population, and are often a recurrent injury at any age. They also are occasionally reduced in the field, and patients arrive at the ED stating that it feels better.

But don’t let that fool you. All known patellar dislocations with successive relocation (spontaneous or procedural) should receive post-reduction films. Close follow-up with an orthopedist and a physical therapist is highly suggested. One of the major concerns for the patient is persistent instability. Be sure to remind your patients, however, that hospitalization for the acute injury is typically not needed.

The Procedure• The patient should be in a supine position.• Place the affected knee further in flexion. You will notice it is already in flexion because the patient cannot extend the leg with a dislocated patella.• Use several rolled up towels or blankets to stabilize the knee at a 90-degree angle. It helps to insert some padding under the patient’s lower back for added comfort because he will have to lie flat and keep his knee/hip in flexion at the same time.• Insert an IV to give the patient pain medication. Standard choices such as IV Dilaudid, morphine, or fentanyl can be used. Note: This is NOT a conscious sedation! Monitor post-procedure per your hospital protocols!• Stand on the patient’s affected side. Place your left hand on the patella like you are holding a potato you want to slice.• Use your right hand to stabilize the lower leg posteriorly and to guide the knee into extension while relocating the patella with your left hand.• Have the patient relax his quadriceps muscle. Lift the leg slightly up and extend the knee out as you push the patella back into the midline with your left hand.• You will meet resistance as you extend the knee while trying to relocate the patella. Give an extra push to the patella more medially at this point while extending the leg in one continuous movement.• You may have to repeat this motion one or two times.• Once the patella is back in place, obtain post-reduction films. Obtain a CT of the knee if you have a high suspicion for tibial plateau fracture.• Wrap the knee with an ACE bandage to assist with swelling or use a knee brace to help maintain stability.• PO narcotics are not always a must because the majority of the pain is now from associated swelling. Ibuprofen 600 mg PO is a nice additional analgesic, if tolerated.• Follow up with orthopedics in a day or two.

Cautions• Transverse fractures of the patella are common. Refer to an orthopedic surgeon as soon as possible if the ruptured fragments of the patella are greater than 2 mm; they may need internal fixation or wiring.• Are there any other injuries? Patella dislocation is painful and distracting. Don’t miss other potential injuries!• Don’t assume that it won’t hurt when you relocate the patella just because the patient has no pain in flexion! Provide pain medication to these patients prior to the procedure.• Do not repair a laceration to the knee before relocating if at all possible. Control the bleeding and return to repair after you have relocated.

Tip of the weekDid you know women who wear high heels might be at greater risk for patellar dislocation? Remind our high-heeled patients that they will NOT be able to wear heels for a few months after their injury. And they should avoid wearing heels in the winter because walking on icy surfaces with a predisposed risk of patella instability will make someone fall harder and faster. This may be basic information to you, but it could be a career changer for some!

Go GreenIf at first you don’t succeed, try, try again. Did you know your hospital most likely stocks spare sterile guidewires, drapes, forceps, etc.? Instead of opening a new package to aid in a procedure (when you accidentally drop the tool on the ground), ask the tech to grab you the missing item. You probably have it just around the corner! Take five minutes to become familiar with your stock closet. Save your hospital money, and be green at the same time. Bonus!

As you may have noticed, we have really put a finger on figuring out paronychia and the dreaded felon in the past two Procedural Pause blogs. This series, however, would not be complete without also touching upon complications related to a subungual hematoma and abscess. Hopefully, this month’s entry will point you in the right direction if you come across these two culprits.

Typically, a subungual hematoma will form from direct blunt trauma to the fingernail itself. Some common mechanisms of trauma range from slamming the digit in a car door, in a drawer, hitting it accidentally with a hammer, or from a sports-related injury. Regardless of the mechanism, the complication remains the same; blood collects under the nail causing increasing pain from the building pressure. Usually the nail itself fares well, but even just a small accumulation of blood under the nail causes intense throbbing pain. Draining the subungual blood immediately relieves pain and helps preserve the integrity of the nail.

A subungual abscess is a party gone wrong between the nail plate and the nail bed. It may form as a complication to a paronychia. If you suspect an abscess, most likely there will be pus within the eponychium as well. Please see the previous blog regarding paronychia treatment.

Recognition and treatment of a subungual complication is a great example of a procedure we can perform for our patients that allows for immediate and satisfying results.

The ApproachTrephination (making a hole) in the nail

The ProcedureSubungual Hematoma• Inspect the nail and eponychium. A large collection of blood under the nail will be dark blue or black. • Test flexor and extensor tendons, capillary refill, and sensation.• Obtain an x-ray to check for a tuft or other fracture.• Obtain a mask, sterile gloves, cautery stick (or heated paper clip), and prepare for trephination.• Clean the finger well. Have the patient wash his hands in the sink, and then clean the area with chlorhexidine or Betadine. Create a sterile field.• A digital block can be used for this procedure, and most patients welcome it, although it is not always required.• If you are using a cautery stick, hold it perpendicular to the nail bed. Insert the red hot tip into the nail plate with quick but stable pressure. You will feel a gentle release once you have entered the area of entrapped blood. Once this happens, you will see blood readily flow from the nail. At first, the blood will drain on its own (it does not clot). To aid in the process once it slows, use your fingers to expel the blood gently from the nail plate.• Note: There are no pain fibers in the nail itself. You will not cause excess pain if you proceed slowly. Avoid hitting the nail bed, which is very sensitive.• Occasionally, you may need to repeat these steps. More than two or three holes are typically not indicated.• Once finished, have the patient wash and dry his hands again. Cover with a dry dressing. Splint injuries as needed. Instruct the patient not to get it wet for two days.• Most likely, the nail will not separate. Provide the patient with appropriate follow-up resources with the surgery clinic or a hand specialist to avoid repeat visits to the ED.• Cultures, soaking, antibiotics, and other invasive treatments are not needed post-evacuation. Always ask the patient, however, if he has diabetes, difficulty healing, or if he is immunocompromised. If this is the case, a short course of Keflex may be indicated when treating subungual hematomas.

Subungual Abscess• These are rare and usually accompanied or complicated by paronychia.• You may relieve the pus from under the nail using the trephenation technique. Ask the patient to complete warm soaks three to four times a day for 10-20 minutes each time for three days, and follow up appropriately.

Cautions• Blood may squirt aggressively during your initial insult to the nail. Do not stand in the line of fire, and use universal precautions.• Patients with Kaposi sarcoma and melanoma may spontaneously form subungual hematomas. Be sure to consider these causes when the patient denies trauma to the digit.• Do NOT remove the nail. Try to preserve the integrity of the nail as much as possible to aid in healing and prevent future complications.• Runner’s toe is not a subungual hematoma. These are not evacuated, and usually resolve on their own.• Dry dressings are used, but a pressure dressing with antibiotic ointment may be considered if the nail is avulsed.

Tip of the weekAre you doing your procedural pause? Right patient? Right site? Right procedure? Please do not forget to ask your patient his name and date of birth and to review allergies before starting any procedure. Ashna Nayyar, a PA at Inova Fairfax Hospital, always knows who she’s dealing with in the pit. She reminds us, when creating a sterile field, remember to remove your lab coat, wash your hands, use appropriate light, and don’t contaminate your area.

Go greenThe cautery stick can only be used for one application; but the batteries can be recycled and used in your pager! I like to take the battery out and hand it to my patients, reminding them to test their smoke detector at home, yet another way we can keep our patients safe and all-around healthy.

Last time we discussed some ways to approach and manage the acute paronychia, but yet another unfortunate criminal robs our nail of its fine fettle: the nefarious felon. The felon’s early signs and symptoms may be subtle so don’t be fooled. This tender, fingerpad infection is not to be ignored. The enclosed fascial spaces of the fingertip pulp will be tender, and appear red and hot, which should mimic your aggressiveness and approach to stop it in its tracks. Figure out that felon, be tender, and forge ahead!

Some thoughts before proceeding. Your fingertip has thousands of nerves, and is very sensitive. Consider all the important things we do with our fingertips; pose for fingerprints, push elevator buttons, play Words with Friends on our iPhones. There are hundreds of reasons why we need to treat this part of our body cautiously and with respect. You can forever destroy the natural fingerprint and leave a tender scar if you make a large incision to drain the area. It could become necrotic and the patient may face amputation if you do not treat the infection. These infections are also very painful, so, please, do a digital block and treat pain appropriately.

The Approach• Digital Block with incision and drainage• Consultation with hand specialist

The ProcedureA felon may develop as a result of trauma to the distal finger or from a foreign body such as a splinter or thorn. It is a closed-space infection, usually caused by Staphylococcus aureus or MRSA. Early identification and treatment is necessary. The provider should always consider complications such as osteomyelitis, cellulitis, nerve degeneration, or even necrosis.

• Disclaimer: Many felons can be treated at the bedside with proper digital block and incision and drainage. Remember to involve your hand specialist early.• Obtain 11-blade scalpel, hemostat, packing material, normal saline, and large syringe with splash guard for wash out. Mask/gown attire with sterile gloves is also recommended.• Have the patient wash his hands with soap and water. Then clean the digit with antiseptic. Generously.• Obtain appropriate set-up for digital block. Bicarbonized lidocaine 1% without epinephrine mixed in a 3:1 ratio with long-acting bupivicaine is a good choice.• Appropriately administer the digital block (to be discussed in future blog).• Consider ordering an x-ray of the affected digit if you suspect osteomyelitis. One caution: osteomyelitis may be insidious in nature and not appear on the x-ray for one to two weeks after the initial presentation of the felon.• Incision (dependent on area of fluctuance) - Approach 1: Make a bilateral incision of the fat pad or a through and through approach. Be cautious of the flexor tendon! - Approach 2: Make a single incision on one side of the fingerpad, and avoid going through to the other side.

This is the safe zone. Make an incision to one or both sides as shown in the diagram. Avoid distal nerves and flexor tendon. (Photo by Martha Roberts.)

• Allow pus or clear liquid to drain. Obtain a wound culture. Break up loculations with your hemostat.• Complete copious wash out with normal saline and jet lavage syringe.• Remove all foreign bodies.• Pack the incision appropriately. If you are using approach 1, you can pull the packing through and through and trim the sides.

(Photo by James Roberts)

(Photo by James Roberts)

• Treat with broad-spectrum antibiotics, such as a cephalosporin. Consider IV vancomycin for complicated infections or osteomyelitis. Antibiotic treatment should continue until the infection has cleared. (See paronychia antibiotic treatment section.) • Apply topical antibacterial ointment and bulky dressing. Consider bacitracin topical 500 units/g, mupirocin topical (2%) applied two to three times a day. This will also prevent the dressing from sticking to the wound, same as paronychia.• Apply a bulky dressing. Finger splinting is not indicated, and may prevent healing.• Follow up with hand specialist in two to three days. Keep clean and dry.• Wash hands twice a day with soap and water. Dressing should remain on for the first 24 hours or at least until packing is removed.• Packing should be removed in 24-48 hours. Consider a repeat digital block when removing the packing.

Cautions• Be familiar with the anatomy of the finger and the flexor tendon. Avoid any incision that may be near the distal interphalangeal crease.• These are complex infections that may be difficult to cure. Complications are not uncommon, especially osteomyelitis.

THE BASICSWhat is more satisfying than draining a pus-filled paronychium? Seeing the look of relief on the face of your patient when his painful, pulsating digit is relieved of all that tension! This rather elementary procedure could be perceived as stale and uneventful for some of you. The more thorough and astute clinicians, however, realize these tiny infections around the nail root may open the door to a mixed bag of insidious and harmful bacterial infections including MRSA, chronic reoccurrences, cellulitis, subungual abscesses, osteomyelitis, herpetic whitlow, or even the dreaded felon.

Whatever your pleasure, this “routine” procedure requires a quick and steady hand by a caring and thoughtful provider. It is important not only to provide immediate and proper pain relief, but also prevent a bounce-back patient who did not understand the discharge instructions. You may not have a fiery passion for a red-hot eponychium, but this procedure is truly appreciated by pediatric and adult patients alike.

THE PROCEDURENot all paronychia require a digital nerve block, but more angry-looking or aggressive digits may require adequate anesthesia. We will highlight digital blocks in future posts of The Procedural Pause.

• Start a warm soak with antibacterial soap when the patient arrives in triage.• Lie the patient comfortably supine on the stretcher with his affected digit on a bulky towel.• Wear a face mask; it helps prevent spreading bacteria while you investigate the wound.• Complete appropriate digital nerve block to the affected digit. The patient will feel immediate relief, and it will allow you to manipulate the finger freely.• Examine the eponychium. Determine which area appears the most engorged. Be sure to look for signs of a felon or subungual abscess.• Most paronychia can be drained by simply lifting up the eponychium to drain the pus, rather than making an incision directly into the skin. A skin incision takes longer to heal and may seem like forever in a diabetic. Holding the blade or needle parallel to the nail bed (NOT at a 90-degree angle), lift up the edge of the eponychium and allow pus drainage. Use a No. 11 blade, scissors, or a 21- or 23-gauge needle.• Fan the blade or tip of the instrument in the cavity to allow more drainage of pus.• A wound culture is an option, but most don't need them because they get better with drainage, and infections are polymicrobial.• Dab the area several times gently with gauze and apply moderate pressure on the nail bed and surrounding skin to improve drainage.• A small piece of gauze packing may be placed under the eponychium for the first 24 hours, but this is most likely not needed. Consider for larger areas of disturbance. Pack similarly to any other abscess I&D.• Apply topical antibacterial ointment and a bulky dressing. Consider bacitracin topical 500 units/g or mupirocin topical (2%) applied two or three times a day. This will also prevent the dressing from sticking to the wound.• Dressing: A soft bulky dressing for a day or two will suffice if no packing is needed.• A finger splint may also be helpful for the patient.• Instruct the patient to keep the area clean and dry for 24 hours and return for packing removal (if any) in 24 to 36 hours.• Remind the patient to complete warm soaks thereafter three to four times a day for the next two to three days.• Antibiotics may be used for two to three days. A cephalosporin would be a reasonable choice, but infections are polymicrobial. Most who have good drainage do not need antibiotics. Instruct the patient to finish all antibiotics until completed (if any, see CAUTIONS section).• Describe signs and symptoms of worsening infection, and advise acetaminophen or ibuprofen for pain control over the next few days. Consider a few Percocet or Vicodin for the road.• For added flair, you may consider referral to your local hand specialist for chronic infections. And we all know our friendly podiatrists always love new patients and the business for those affected with toe paronychia.• Update the tetanus for completeness.

Photos by Martha Roberts

CAUTIONS• Contrary to belief, nail/skin cutting or removal is rarely indicated for most paronychia. It can delay healing so try to avoid this approach.• If you start hot soaks early upon the patient’s presentation while in triage, you may see a significant improvement in just 20 minutes.• Antibiotic use is subject to presentation. Be sure to cover for Staphylococcus. Consider gram-negative anaerobes, however, in young children or those with frequent nail biting.• Also consider viral causes, including herpes simplex virus, which causes herpetic whitlow. A Tzanck smear will test for herpetic causes.• Always check for a felon or cellulitis; suspect osteomyelitis.• Antibiotics to consider: First generation cephalosporin such as cephalexin 500 mg qid for 7-14 days or antistaphylococcal penicillin such as dicloxacillin 500 mg PO qid 7-14 days. PCN allergy? Consider clindamycin 300 mg PO qid for 7 days. Diabetic patients may need extended day coverage.• Presumed oral flora infection? Try amoxicillin-clavulanate (875/125 mg) bid for 7 days.• High-risk jobs associated with paronychia include nail technicians, dish washers, chefs, and meat packers.• Final precautions: osteomyelitis, septic arthritis, separation of nail plate from matrix.

TIP OF THE WEEKStretcher anyone? Eugene Lee, MD, from Inova Fairfax Hospital prefers to lie his patient completely supine for this procedure. Not only does this make it more comfortable for the patient, but Dr. Lee doesn’t have to worry about a sudden syncope. The pain can be intense and patient comfort is a must.

It's Sunday evening, and a patient with tooth pain signs into triage. This pleasant but teary 44-year-old woman had a root canal two days earlier. Many ED providers would agree that dentists should not schedule root canals on Fridays unless they are truly emergent.

But the patient is in the ED asking for your expert dental advice. The good news is you can assist her temporarily until she gets back to her dentist. This quick and effective ED procedure will save you time and heartache.

THE BASICS

No other medical problems or surgeries.

Allergies: ASA, NSAID.

The culprit: Tooth #17

Medications tried: Vicodin, Percocet, and Tylenol, all to no avail.

PE: Negative except severe pain in the tooth itself, no gum involvement, no signs of infection, or abscess.

THE APPROACH

Inferior Alveolar Nerve (IAN) Block.

THE PROCEDUREThe IAN block provides anesthesia to all the teeth on the side of the mandible of injection. It also numbs the lower lip and chin.

Prefill (away from the patient) a 5 mL syringe with bupivacaine

Attach 25 g 1.5 inch needle to syringe.

Position the patient sitting upright at a 90-degree angle. Lying flat is also an option.

Stand on the opposite side of intended injection, and use good light. Have an assistant hold a light source if needed to better visualize the site.

Dry the area of injection with gauze.

Remove gauze. Spray topical 20% benzocaine (HurriCane spray) to the site. Option: Saturate two cotton tip applicators with benzocaine. Place cotton tips on injection site for five minutes.

Have patient close his eyes, and stay very still. You do not want his head to move.

Place your thumb on the side of the cheek next to the site of injection with fingers grabbing jaw slightly like you would hold a large mouth bass.

Advance needle slowly into the mouth, avoid nicking lips or tongue; the needle pinch may initially startle the patient.

Injection is made at the retromolar fossa, 1 cm above the occlusal surface of the molars.

Slowly advance the needle while aspirating and injecting until you reach the bone. Withdraw slightly and inject 3 mL of bupivacaine. Note: Larger volume allows for error of needle placement. Option: Use bupivacaine with epinephrine for longer action if patient has no contraindications.

Numbness will occur within three to five minutes of injection. Effects usually last five to eight hours, just enough time to get back to the dentist at 8 a.m.